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CESARIAN DELIVERY,
VBAC(Vaginal Birth After Caesarean section)-TOLAC(
Trial of Labor After Caesarean section)
Prepared by; ANDREA MASHIKU
1
OUTLINE
 Introduction
 Epidemiology
 Indications/Contraindications
 Classifications
 Pre-Op preparation
 Procedure
 Post-Procedure
 Complications
 Introduction
CESARIAN SECTION(CS)
• It is an operative procedure whereby the fetuses after the
end of 28th weeks are delivered through an incision on the
abdominal (laparotomy)and uterine (hysterotomy) walls.
• The first operation performed on a patient is referred to as a
primary caesarean section.
• When the operation is performed in subsequent
pregnancies, it is called repeat caesarean section.
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4
• Pompilius II in 720 BC enacted a law, the Rex Cesare,
from which the Rex Regis was derived
• Thelaw required that infants be delivered
abdominally after maternal death to facilitate
separate burial
• Surviving children thus born were called caesones
5
• The term, 'caesareansection' is regarded by some as tautology as the words
'caesarean' and 'section' may have been derived from the Latin words 'caedere'
and 'seco' respectively, both meaning 'to cut’
• Thisprocedure is currently being performed for o variety of fetal and maternal
indications, and such indications hove expanded to consider the patient's wishes
andPrefrefences
• The following historical points ore worth noting:
"Earliestreport of surviving infant,508BC[Gorgias of Sicily]
;. First performed on a living patient, 1610.She died 25 days later
6
 EPIDEMIOLOGY
• The CSR varies from country to country, and in a country like ours,
varies from region to region
• The ideal CSR according to WHO in 1985 is between 10 and
15%, as rates higher than these at the population level are not
associated with reductions in maternal and newborn mortality
rates
7
• Frequency and rates:
- USA, rose from 4.5% in 1965 to 32.9% in 200
- England and Wales, from 4% in 1970 to 2 1 .3% in
2000
- Ghana, 2 1 % [Kwaw ukume, 2002)
- Nigeria, rose from 9.4% in 1970s to 34.6% in 2002
[/ bekwe PC, 2004)
 Indications of caesarean section
The indications are broadly divided into two categories: We
have Absolute and relative(common) indications but can be
further subdivided into maternal or fetal and combined
fetal- maternal indications
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In absolute Indications; Vaginal delivery is not possible. Caesarean
is needed even with a dead fetus.
a. Central placenta previa (maternal- fatal)
b. Severe PE/ E with unfavorable cervix (maternal)
c. Previous classical or T Shaped(maternal)
d. Transverse lie in labor(fetal)
e. Contracted pelvis or feto-pelvic disproportion(maternal-fetal)
f. Pelvic mass causing obstruction(maternal)
g. Advanced carcinoma cervix and Vaginal obstruction (atresia,
stenosis)(maternal)
h. Prime gravida with breech presentation
Relative Indications; In these indications, vaginal delivery may be
possible but risks to the mother and/or baby are high.
a. Previous caesarean delivery
b. Non-reassuring FHR (fetal distress)
c. Dystocia may be due to (three Ps) relatively large fetus
(passenger), small pelvis (passage) or insufficient uterine
contractions (power)
d. Antepartum hemorrhage
e. Conjoint twins
NOTE; Caesarean delivery on maternal request also can be done
11
f. Malpresentation: Breech, or shoulder (transverse lie)
g. Hypertensive disorders
h. Medical-gynaecological disorders: (a) Diabetes
(uncontrolled), heart disease (coarctation of aorta,
Marfan’s syndrome; (b) mechanical obstruction (due to
benign or malignant pelvic tumors (carcinoma cervix), or
following repair of vesicovaginal fistula
12
 Common indications of caesarean section for primigravidae
• Failed indication
• Fetal distress (non reassuring fetal FHR)
• Feto-pelvic disproportion (CPD)
• Dystocia ( nonprogress of labor)
• Malposition and malpresentation (occipitoposterior,
breech).
13
 For, Mutigravidae, the followings are the common
indications,
• Previous caesarean delivery
• Antepartum hemorrhage (placenta previa, placental
abruption)
• Malpresentation (breech, transverse lie)
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 Classifications
• Based on timing at the time of decision making
[RCOG2001)
- Category 1:emergency-there's immediate threat to mother
and fetus. Surgeryshould be within 30minutes
- Category 2: urgent-fetal or maternal compromise not
immediately life threateninge.g.,fetalheartrate
abnormalities. Surgery should be within 1 hour
16
- Category 3: scheduled -mother needs early delivery but there
is no compromise to either e.g.,failure to progress, pre-
eclampsia with gradually worsening lab parameters. Surgery is
planned for a few hours to a few days
- Category4: elective- delivery is timed to suit mother and staff
17
• In 1996, Robson and co devised asystem of classification dividing all
pregnant women using a maternity service into 10groups
• This system has been adapted my several authorities with modification,
including the WHO
• This classification is used in assessing and comparing various health
facilities on the basis of modes of delivery
• The system uses 5 parameters, viz:
- Obstetric history [parity, previous c/s}
- Onset of labor [spontaneous, induced]
- Lieandpresentation
- Number of fetuses
- Gestational age [term, preterm]
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TYPES OF OPERATION:
There are two types of operations;
1. Lower segment
2. Classical or upper segment
28
1. Lower segment.
• In this operation, the extraction of the baby is done through
an incision made in the lower segment through a
transperitoneal approach.
• It is the only method practiced in present day obstetrics, and
unless specified, caesarean section means lower segment
operation.
29
2. Classical or upper segment
• In this operation, the baby is extracted through an incision
made in the upper segment of the uterus.
30
LOWER SEGMENT CESAREAN SECTION (LSCS)
Preoperative preparation.
• Obtain informed consent; Informed written permission for
the procedure, anaesthesia and blood transfusion is obtained.
• For elective cases, patient should fast as follows
2 hours from clear fluids, 6hoursfromlightmeal, 8 hours
from regular meal
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• Abdomen is scrubbed with soap and nonorganic iodide lotion.
• Premedicative sedative must not be given
• Nonparticulate antacid (0.3 molar sodium citrate, 30 mL) is given
orally before transferring the patient to theatre. It is given to
neutralize the existing gastric acid.
• Anaesthesia mostly regional (epidural or spinal) also general
anaesthesia in some cases
33
• Lab investigations
- FBC, Cr, clotting profile, urinalysis
- Screen for transmissible diseases
- Group and cross match blood
• Imaging studies to confirm lie, presentation, placentation
• Before taking patient to theatre
-urinary catheter
- antiacid
-antibiotic prophylaxis (gentamycin and clindamycin,
ceftriaxone if c/s last >3hrs the an additional doses is needed
Position
• Supine position in 15 degree left lateral tilt
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 Abdominal preparation
- Used to include shaving maternal abdomen the night before
surgery
- Current recommendation is to shave in the theatre,just beforeskin
preparation
- Shaving the night before actually increases the bacterial count on the
maternal abdomen
- Shave only hairs that physically interfere with the procedure itself
- Thereisnoreasontoshaveformostof thepatients
36
 Skin preparation: the Association of Surgical Technologists,
AST, recommendations amongst others, [WEF 2008]
I. Patient to bathe or shower the night before surgery with an
antiseptic,chlorhexidine gluconate, CHG
II. Alcohol is anaccepted antiseptic agent, but should not be used
asasingle agent
III. Contaminated areasrequirespecial attention andshould be
prepped last
37
Surgical Safety Check-list
 Briefing-beforeinductionofanaesthesia
- Anaesthesia equipment safety check
- Confirm patient information
- Review final test results
- Confirm essential imaging displayed
- ASAclass
- Allergies
-Medication
38
- Venous thromboembolism prophylaxis
- Difficult airwayIAspiration risk
- Monitoring devices
- Anticipated blood loss
- Reviews-surgeon(s), anesthesiologist(s), nurse(s)
- Patient positioning and support
- Expected procedure time /Post-Op destination
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• Time out -Before skin incision
- Team members introduce selves by name and role
- Team members verbally confirm 'brief'
- "Does anyone have any other questions or concerns before
proceeding?
40
• Debriefing -Before patient leaves theatre
- Surgeon and team members review
• Procedure
• Important intra-op events
• Fluid balance
- Anesthesiologist and team members
review
• Important intra-op events
• Recovery events
41
• Debriefing-Beforepatient leavestheatre
- Nurse(s) and team members review
• Instruments IspongeIneedlecounts
• Specimen labelling and management
• Important intra-op events
42
Procedure
• Involves the following steps
- Laparotomy
- Hysterotomy
- Delivery of the fetus and placenta
- Uterinerepair
- Closure
Anatomical layer
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 Laparotomy
- Approximate length of 15 cm or more
- Excision of previous scar is essential for better results and
cosmetic appearance
- Includes the following
• Midline infraumbilical [longitudinal]
• Maylard [ transverse]
• Joel-Cohens [transverse]
• Pfannenstiel [ transverse]
• paramedian [longitudinal]
46
• Midline infraumbilical
- Provides quicker access to the uterus
- Associated with less blood loss
- Gives good exposure to abdominal and pelvic organs
- The rectus sheath is either incised along the length with a scalpel,
or a small incision is made and extended with scissors
- Peritoneum is entered at thesuperior aspect of the incision to
avoid bladder injury
- Wound dehiscence due to low blood supply
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• Paramedian
- Used if classical c/s is contemplated
- The upper 1/3rd is above the umbilicus
- The lower 2/ 3rd is below the umbilicus
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• Pfannenstiel
- A transverse incision 3 cm above the symphysis pubis, curved slightly
cephalad
- Extends slightly beyond the lateral borders of the rectus muscle bilaterally
y and carried to the fascia
- The fascia's is incised bilaterally along thefull length of the incision
- Underlying rectus muscles separated from the fascia both superiorly and
inferiorly with blunt and sharp dissection
- Rectus muscle separation
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• Maylard
- Made 2-3 cm above the symphysis pubis
- Involves transverse incision of the anterior rectus sheath bilaterally
and the medial 2/3rd of the rectus muscles are divided bilaterally
- Thesuperficialinferior epigastricvessels are identified and ligated
bilaterally
- Transversalis faciaand peritoneum are identified andincised
transversely
- Gives better access and quicker than Pfannenstiel
50
• Joel-Cohens
- A straight transverse incision made 3 cm below a linejoining the anterosuperior iliac
spines
- Incision is carrieddown to the anterior sheath of the rectus fascia
- 3-4 cm incision is made here and bluntly opened by stretching in a craniocaudal
fashion
- Therectus muscles areretracted laterally and parietal peritoneum bluntly opened by
digital dissection
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• Transverse [vs longitudinal] :
- Takeslightly longer to enter the peritoneal cavity
- Are less painful
- Have with less risk of developing incisional hernia
- Pref erred cosmeticallyy
- Preferred whenoperating on theobese
Limits view of the upper abdomen
Cannot be further extended if needed
Less risk of fever
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• Access the degree of rotation by palpation.
It's commonly dextrorotated
• Retract the bladder
• Pack theparacolic gutters
• Hysterotomy
- Low transverse [Kerr]
- Low vertical [De Lee]
- J-shaped
- U-shaped
- Inverted T
- Classical
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 Low transverse [Kerr]
• Less incisional site bleeding
• Easier to repair
• Relatively non contractile portion
• Healing better
• Risk of uterine rupture in subsequent pregnancy <0.2-0.9%
STEP 1;The loose peritoneum above the bladder reflection is
grasped with forceps and incised with Metzenbaum scissor
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STEP 2 ;This peritoneal edge is elevated and incised laterally
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Cross section shows blunt dissection of the bladder off the
uterus to expose the lower uterine segment.
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STEP3; the myometrium is incised with shallow strokes to
avoid cutting the fetal head.
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STEP4; After entering the uterine cavity, the incision is
extended laterally with fingers or with bandage scissors (inset).
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• Low vertical [De Lee]
- Indicated in poorly formed LUS, such as in preterm deliveries
- They avoid the uterine arteries bilaterally
- A trial of labor is possible in subsequent pregnancies
- Risk of uterine rupture in subsequent pregnanciesis less than 1.5%[5]
- Requires extensive bladder dissection to keep the incision 10-12 cm in the LUS
- There may be an unwanted extension of the incision towards the bladder
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• J-Shaped
- Used in difficult situations that may require extension of a
transverse incision to the upper segment
- The extension is made on the most accessible part of the
uterus
- There is a greater risk of uterine rupture is subsequent
pregnancies
- Increases the duration of surgery
- Example is shoulder impaction mistaken for breech
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• U-Shaped
- Indicated in the delivery of an impacted fetal head
- Has more room bilaterally than the Kerr incision
- Incision is made with a broad base, the convexity towards the
pelvis and the ends cephalad
- Less risk of lateral extension and injury to uterine vessels
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• Inverted T
- Similar indication as for J-Shaped incision
- Both are associated with more blood loss
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• Classical
- Incision is made 10 cm on the anterior surface of the
uterus
- Should be done quickly because of the risk of hemorrhage is
greater
- Risk of cutting the fetus is greater than in all the afore
mentioned
- Delivery should be by breech extraction
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• Classical [indications]
- Transverse lie with back down, ruptured membranes and
hand prolapse
- Large fibroids in the LUS
- Preliminary to caesarean hysterectomy
- Very thin previous classical scar
- Preterm breech with ruptured membranes
- Extreme prematurity, before of the LUS (LUS not formed)
- Dense adhesions in LUS
- Cancer of the cervix
- Morbidly adherent placenta in the LUS especially anterior
located placenta
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• Classical [advantages]
- Rapid entry into the uterus
- No lateral extension into the vessels of the broad ligaments
- Easy entry into the uterus when there is fibroids in the
lower uterine segment
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• Classical [disadvantages]
- Increased intra-op blood loss
- High risk of adhesion formation
- High risk of uterine rupture in subsequent
pregnancies 2-9%
- Less chance of VBAC
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• Delivery of the baby [breech]
- Manipulate feet to uterine incisionand deliver by
extraction
- Deliver arms and head, maintaining flexion of the head
• Delivery of the baby [transverse]
- Convert to cephalic and deliver
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• Special situations
- Bandl's [pathological retraction] ring
• Incise through the ring
• IV nitroglycerin may be used to relax uterus
- Anterior placentaprevia
• Insinuate thehand between the uterine walls and
placenta to reach the membranes and quickly
deliver the baby
• The cord is cut in between two clamps and the baby is
handed over to the pediatrician. The Doyen’s retractor is
reintroduced.
• The optimum interval between uterine incision and delivery
should be less than 90 seconds. Interval > 90 seconds are
associated with poor Apgar scores. There is reflex uterine
vasoconstriction following uterine incision and manipulation.
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• Delivery of the placenta
- Cord traction
- Manual delivery
- Spontaneous expulsion
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Removal of the placenta and membranes:
• By this time, the placenta is separated spontaneously. The
placenta is extracted by traction on the cord with
simultaneous pushing of the uterus towards the umbilicus
per abdomen
• using the left hand (controlled cord traction). Routine
manual removal should not be done. Advantages of
spontaneous placental separation are: less blood loss and
less risk of endometritis.
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• The membranes are carefully removed preferably intact and
even a small piece, if attached to the decidua should be
removed using a dry gauze.
• Dilatation of the internal os is not required. Exploration of
the uterine cavity is desirable.
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• Closure
- Inspect pelvis and exclude injury to adjacent organs
- Remove any clots seen or any instrument and gauzes
- Irrigation may or may not be performed
- Noneed to reapproximate theperitoneum ormuscle
- Close the rectus sheath with PGA or nylon 1
- Close subcutaneous tissue if >2 cm
• First layer: The first stitch is placed on the far side in the
lateral angle of the uterine incision and is tied. The suture
material is No “0” chromic catgut or vicryl and the needle is
round bodied.
• A continuous running suture taking deeper muscles
excluding or including the decidua (very difficult to exclude)
ensures effective apposition of the tissues; the stitch is
ultimately tied after the suture includes the near end of the
angle
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Second layer:
• similar continuous suture is placed taking the superficial
muscles and adjacent fascia overlapping the first layer of
suture. Uterine muscles may be closed using a continuous
single layer stitch taking full thickness muscle and decidua.
• There is controversy as regard the place of single layer or
double layer closure in relation to the risk of subsequent scar
rupture. The peritoneal flaps may be apposed by continuous
inverting suture (to prevent any raw surface).
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• Closure of rectus sheath by continuous suture
• Subcutaneous fat can be sutured in obese but it is not
required mostly
• Skin closure by simple interrupted suture or sub Q
• Occlusive dressing
• Vaginal toileting
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 Postoperative care
• Vital signs every 15 min for the first 1-2 hours
• Urine output monitoring hourly
• Palpate uterus to ensure it feels firm
• Any active bleeding par vagina?
• Ensure adequatepain control
• Fluidmanagement3-4Linthefirst24hourspost op
• Remove catheter after 12-24 hours
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• Oralsips may bestarted within 12-24 hours and advanced accordingly
• Encourage early ambulation by 151 post-op day
• Encourage early initiation of breastfeeding if patient plans to breastfeed
• Post-op PCV check by 151 post-op day
• Patient may be discharged by day 3-4 if no complication
• Oxytocic's: Injection oxytocin 5 units IM or IV (slow) or methergine 0.2 mg IM
is given and may be repeated.
• Prophylactic antibiotics; (cephalosporins, metronidazole) for
all caesarean delivery is given for 2–4 doses. Therapeutic
antibiotic is given when indicated.
• Analgesics; in the form of pethidine hydrochloride 75–100
mg is administered and may have to be repeated
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• Baby is put to the breast for feeding after 3–4 hours when
mother is stable and relieved of pain.
• Day1: Oral feeding in the form of plain or electrolyte water
or raw tea may be given. Active bowel sounds are observed
by the end of the day.
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• Day2: Light solid diet of the patient’s choice is given. Bowel
care: 3–4 teaspoons of lactulose is given at bed time, if the
bowels do not move spontaneously
• Day 5 or day 6: The abdominal skin stitches are to be
removed on the D-5 (in transverse) or D-6 (in longitudinal)..
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Discharge:
• The patient is discharged on the day following removal of
the stitches, if otherwise fit.
• Usual advices like those following vaginal delivery are given.
Depending on postoperative recovery and availability of care
at home, patient may be discharged as early as third to as
late as seventh postoperative days
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 Complications of caesarean sections.
Intraoperative complications.
• Extension of uterine incision to one or both the sides
• Uterine lacerations at the lower uterine incision
• Bladder injury; is rare in a primary CS but may occur in a
repeat procedure.
• Ureteral injury is rare (1 in 1,000 procedures). Injury occurs
during control of bleeding from lateral extensions.
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• Gastrointestinal tract injury is rare unless there is prior
pelvic/abdominal adhesion
• Hemorrhage may be due to uterine atony or uterine
lacerations. Medical management should be started.
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Postoperative complications
• Can be immediate or remote
Immediate;
• Postpartum hemorrhage
• Shock
• Anesthetic hazards
• Infections
• Intestinal obstruction
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• Deep vein thrombosis and thromboembolic disorders.
• Wound complications,
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Remotes;
• Gynaecological: Menstrual excess or irregularities, chronic
pelvic pain or backache.
• General surgical: Incisional hernia, intestinal obstruction due
to adhesions and bands.
• Future pregnancy: There is risk of scar rupture.
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VAGINAL BIRTH AFTER CESAREAN (VBAC) DELIVERY
AND TRIAL OF LABOR AFTER CESARIAN(TOLAC)
Vaginal birth after caesareans section
Term applied to women who undergo vaginal delivery
following caesarian delivery in a prior pregnancy
Trial of labor after caesarean;
Is a planned attempt to labor by a woman who has
previously undergone caesarean delivery and desire
subsequent vaginal delivery
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Few issues in modern obstetrics' have been as controversial as
management of the women who has had a prior caesarean
delivery
For many decades a scarred uterus was believed by most to
contraindicate labor out of fear of uterine rupture
In 1916 Cragnin made his famous quotation and now seemingly
excessive pronouncement “once a caesarean always a caesarean”
97
In 1920s the technique of low transverse uterine incision
was introduced by Kerr
A large number of women may have successful and safe
vaginal birth after c/s with reported figures of 70% to 80%
(flamm etal 1990)
American College of Obstetricians and Gynecologist
concurs and states “most women with one previous c/s
with a low transverse incision are candidates for and
should be counseled about VBAC and offered TOLAC
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Selection criteria for VBAC-TOLAC
• Informed consent of the woman
• One or two previous lower segment transverse scar
• Nonrecurring indication for prior caesarean section
• Vertex presentation( cephalic)
• singleton
• Availability of resources (anaesthesia, blood transfusion and
theatre) for emergency caesarean section within 30 minutes
of decision
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Pregnant women with a previous caesarean section
can deliver in one of the following ways
Trial of labor after previous caesarean delivery ending
in vaginal birth
Trial of labor after previous caesarean delivery ending
in emergency caesarean section
Planned elective repeat caesarean section
NOTE; TOLAC should be undertaken in facilities with
staff immediately available to provide emergency care
101
Some factors that influence a successful trial of labor in a woman with prior
caesarean delivery
 Type of prior uterine incision
 Prior uterine rupture; Women who have previously sustained a uterine rupture
are at greater risk for recurrence. As shown in Table 31-3, those with a previous
low-segment rupture have up to a 6-percent recurrence risk, whereas prior upper
segment uterine rupture confers a 9- to 32-percent risk (Reyes-Ceja, 1969; Ritchie,
1971)
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Interdelivery interval Magnetic resonance imaging studies
of myometrial healing suggest that complete uterine
involution and restoration of anatomy may require at least 6
months (Dicle, 1997) Stamilio and associates (2007) noted a
threefold augmented risk of uterine rupture in women with
an interpregnancy interval. So ideal time is at least 18
months
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 Closure of prior incision; A metanalysis by Roberge and colleagues (2014)
compared single- versus double-layer closure and locking versus unlocking
suture for uterine closure They reported that rates for uterine dehiscence or
uterine rupture for these closures did not differ significantly.
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 Prior vaginal delivery
Either before or after a caesarean birth, improves the
prognosis for a subsequent vaginal delivery with either
spontaneous or induced labor (Aviram, 2017; Grinstead,
2004; Hendler, 2004; Mercer, 2008). Prior vaginal delivery
also lowers the risk of subsequent uterine rupture and other
morbidities (Cahill, 2006; Hochler, 2014; Zelop, 1999)
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Prior second-stage caesarean delivery can be associated with second-stage uterine rupture in a subsequent pregnancy
(Jastrow, 2013).
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 Multifetal gestation
• Twin pregnancy does not appear to increase the risk of uterine rupture with
VBAC
• Ford and associates(2006) analyzed the outcomes of 1850 such women with a
prior caesarean delivery who attempted a trial of labor . The uterine rupture
rate was 0.9% and the rate of successful vaginal delivery was 45%
• Cahill(2005) and Varner (2007) and their colleagues reported ruptures of 0.7 to
1.1 percent and vaginal delivery rate of 75 to 85 %
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Maternal obesity
Obesity decrease the success of VBAC
Hibbard and colleagues(2006) reported the following
vaginal delivery rates: 85% with a normal body mass index ,
78% with a BMI between 25 and 30, 70%with a BMI
between 30 to 40, and 61 %with a BMI of more than 40or
more
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 Antenatal care
Counseling regarding mode of delivery should ideally start at the time of the sentinel
caesarean
Women should be offered information regarding the need for the first caesarean and
implication if may have for future pregnancies and deliveries
Identify, at the first antenatal visit all women who have had a previous caesarean
section or have a uterine scar a senior consultant should anesthesiologist
112
Factors to note at the booking visit include
Number and type of previous uterine scars, indications for prior c/s there any puerperal complications,
gestation at time of prior c/s interconception interval and other associated medical complication
Anticipated family size: this is important as the longer term risks related to further repeat c/s may be
taken into consideration (placenta previa, placenta accreta, blood loss, transfusion, hysterectomy and
mortality
History of a successful vaginal delivery and whether this was before or after the uterine scar. The rupture
rate rises with each successive labor but a prior vaginal delivery also increases the chances of a
successful VBAC attempt
113
• Antenatal counseling
• Women with prior history of on uncomplicated LSCS, in an otherwise
uncomplicated pregnancy at term, with no contraindication to vaginal birth,
should be able to discuss the option of planned VBAC and the alternative
on an elective repeat c/s
• The antenatal counselling of women with a prior c/s birth should be
documented in the notes. A patient information leaflet should be provide
with the consultation
• A final decision fore mode of delivery for mode of birth should be agreed
between the woman and her obstetrician before the expected /planned
delivery date, ideally by 36 weeks of gestation
• Placenta previa/accreta should be excluded with USG. Identifying and
treating anemia early on is important in these women
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• If decision is made for TOLAC, the woman should be advised
• To present to the obstetric unit early in labor
• That the decision made in the antenatal clinic is not binding
• To have a clear understanding with the obstetric team which states
the boundaries of safe practice to which they have agreed and
indicate the circumstances under which they would request that a
repeat c/s be carried out
• The decision should be clearly documented in the antenatal records
115
Candidates for a TOLAC
Some factors for consideration in selection of candidates for vaginal birth after caesarean delivery
• One previous low transverse caesarean delivery
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Physician immediately available throughout active labor capable of monitoring labor and
performing an emergency caesarean delivery
• Availability of anaesthesia and personnel for emergency caesarean delivery
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Contraindications for VBAC-TOL
• Previous classical or inverted T-shaped uterine incision ;uterine incision
that has involved the whole length of the uterine corpus(200-900/10000
incidence)
• Previous two or more lower segment caesarean section
• Pelvis contracted or suspected feto-pelvic disproportion
• Presence of other complications in pregnancy: Obstetric (preeclampsia,
malpresentation, placenta previa) or medical
• Resources limited for emergency caesarean delivery
119
…
• patient refusal for VBAC-TOL
• History of prior uterine rupture ;risk of recurrent rupture is
unknown
• Blood in urine
• Tenderness of the scar
• Meconium stain
• Fetal tachycardia
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Intrapartum Management
Women who have had a previous caesarean section should be offered care during labor in a unit where:
 There is immediate access to caesarean section.

 There are on site blood transfusion services or blood can be obtained with in a reasonable amount of
time.

 Facilities for continuous fetal heart monitoring are available, preferably electronic fetal heart
monitoring.

 Specialist obstetricians, anesthetists and pediatrician are available round the clock
122
Continuous fetal monitoring
• Continuous electronic fetal monitoring is recommended following the onset of uterine contractions for the duration
of TOLAC.
• An abnormal CTG is the most consistent finding in uterine rupture and is present in 55% to 87% of these
events(guise et al 2004)
• Partogram for progress of labor;Partographic progress of labor enhances safety. A partogram, in addition to
monitoring progress of labor, enables effective monitoring of maternal parameters like blood pressure and pulse
rate.
• The duration of labor should be closely monitored with special reference to alert and action line on partogram.
Prolongation of labor is an important sign of dystocia
123
Analgesia
• Epidural analgesia for labor may be used as part of TOLAC, and adequate pain
relief may encourage women to choose TOLAC (sakala et al 1990, flamm et al
1998).
• In addition effective regional analgesia should not be expected to mask signs
and symptoms of uterine rupture, particularly because the most common sign
of rupture is FHR tracing abnormalities.
124
Early diagnosis of uterine rupture
Early diagnosis of uterine scar rupture followed by expeditious laparotomy and resuscitations essential to reduce
associated morbidity and mortality and infants.
There is no single pathognomonic clinical feature that is indicative of uterine rupture but the presence of any of the
following peripartum signs and symptoms should raise the concern of the possibilities of uterine rupture (turner
2002)
Abnormal CTG tracing, severe abdominal pain persisting in between contractions, chest pain or shoulder tip pain,
acute onset scar tenderness, abnormal vaginal bleeding and hematuria, cessation of previously efficient uterine
activity, maternal tachycardia, hypotension or shock, loss of station of the presenting part.
125
Delivery
The length of the second stage should not exceed 2 hrs. one hour to allow passive descent, but no
more than one hour for active pushing (or 30 minutes if the woman has had a prior vaginal delivery).
Assisted delivery in the presence of a prior uterine scar, should ideally only be performed by an
experienced consultant. This should be in the operating theatre with provision for immediate
caesarean section.
Excessive vaginal bleeding or signs of hypovolemia are potential signs of uterine rupture and should
prompt complete evaluation of the genital tract (cahill etal 2005)
126
Role of induction and augmentation of labor in VBAC
Women with a previous caesarean should be informed of the two to three fold increased
risk of uterine rupture and around 1.5 fold increased risk of caesarean section in induced
labors compared with spontaneous labor.2
Lydon-Rochelle and associates (2001) performed a retrospective population-based study.
They found that induction of labor with prostaglandins for VBAC increased the uterine
rupture risk more than 15-fold compared with elective repeat caesarean delivery.1
Benefit for VBAC-TOLAC
• Decreased maternal morbidity (infection and others)
• Reduced length of hospital stay
• Decreased need for blood transfusion
• Decreased risk of abnormal placentation
• Decrease need for successive caesarean delivery in next
pregnancy
127
Complications of Unsuccessful VBAC-TOL
Maternal
Uterine wound dehiscence
 Uterine rupture (0.5–1%) ;the most common sign of uterine rupture is a
nonreassuring fetal heart rate pattern with variable decelerations that may evolve into late
decelerations and bradycardia, hemoperitoneum from a ruptured uterus may result in
diaphragmatic irritation with pain referred to the chest.
 With rupture, the only chance of fetal survival is afforded by immediate delivery—most often by
laparotomy—otherwise, hypoxia is inevitable. If rupture is followed by total placental separation,
then very few neurologically intact fetuses will be salvaged. Thus, even in the best of
circumstances, some fetal outcomes will be impaired.
128
129
Increased blood transfusion
Increased risks of hysterectomy due to uterine rupture
Infections,
increased maternal morbidity
…
Perinatal:
• Low Apgar score,
• admission to NICU,
• hypoxic ischemic encephalopathy (HIE),
• neonatal death, rarely stillbirth
130
References
131
• Hiralal Konar (2015-05-10) DC Dutta's Textbook of Obstetrics. JP
Medical Ltd.
• F. Gary Cunningham, Kenneth J. Leveno, Jodi S. Dashe, Barbara L.
Hoffman, Catherine Y. Spong, Brian M. Casey (2022-04-05) Williams
Obstetrics 26e. McGraw Hill Professional.
• caesarean delivery. [Online] Available at:
https://www.slideshare.net/imezi/caesarean-delivery?from_search=4
[Accessed: 24 March 2024]
• Philip N. Baker, Louise Kenny (2011-03-25) Obstetrics by Ten Teachers,
19th Edition. CRC Press.

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CESAREAN DELIVERY AND VAGINAL DELIVERY AFTER CAESAREAN SECTION

  • 1. CESARIAN DELIVERY, VBAC(Vaginal Birth After Caesarean section)-TOLAC( Trial of Labor After Caesarean section) Prepared by; ANDREA MASHIKU 1
  • 2. OUTLINE  Introduction  Epidemiology  Indications/Contraindications  Classifications  Pre-Op preparation  Procedure  Post-Procedure  Complications
  • 3.  Introduction CESARIAN SECTION(CS) • It is an operative procedure whereby the fetuses after the end of 28th weeks are delivered through an incision on the abdominal (laparotomy)and uterine (hysterotomy) walls. • The first operation performed on a patient is referred to as a primary caesarean section. • When the operation is performed in subsequent pregnancies, it is called repeat caesarean section. 3
  • 4. 4 • Pompilius II in 720 BC enacted a law, the Rex Cesare, from which the Rex Regis was derived • Thelaw required that infants be delivered abdominally after maternal death to facilitate separate burial • Surviving children thus born were called caesones
  • 5. 5 • The term, 'caesareansection' is regarded by some as tautology as the words 'caesarean' and 'section' may have been derived from the Latin words 'caedere' and 'seco' respectively, both meaning 'to cut’ • Thisprocedure is currently being performed for o variety of fetal and maternal indications, and such indications hove expanded to consider the patient's wishes andPrefrefences • The following historical points ore worth noting: "Earliestreport of surviving infant,508BC[Gorgias of Sicily] ;. First performed on a living patient, 1610.She died 25 days later
  • 6. 6  EPIDEMIOLOGY • The CSR varies from country to country, and in a country like ours, varies from region to region • The ideal CSR according to WHO in 1985 is between 10 and 15%, as rates higher than these at the population level are not associated with reductions in maternal and newborn mortality rates
  • 7. 7 • Frequency and rates: - USA, rose from 4.5% in 1965 to 32.9% in 200 - England and Wales, from 4% in 1970 to 2 1 .3% in 2000 - Ghana, 2 1 % [Kwaw ukume, 2002) - Nigeria, rose from 9.4% in 1970s to 34.6% in 2002 [/ bekwe PC, 2004)
  • 8.  Indications of caesarean section The indications are broadly divided into two categories: We have Absolute and relative(common) indications but can be further subdivided into maternal or fetal and combined fetal- maternal indications 8
  • 9. 9
  • 10. 10 In absolute Indications; Vaginal delivery is not possible. Caesarean is needed even with a dead fetus. a. Central placenta previa (maternal- fatal) b. Severe PE/ E with unfavorable cervix (maternal) c. Previous classical or T Shaped(maternal) d. Transverse lie in labor(fetal) e. Contracted pelvis or feto-pelvic disproportion(maternal-fetal) f. Pelvic mass causing obstruction(maternal) g. Advanced carcinoma cervix and Vaginal obstruction (atresia, stenosis)(maternal) h. Prime gravida with breech presentation
  • 11. Relative Indications; In these indications, vaginal delivery may be possible but risks to the mother and/or baby are high. a. Previous caesarean delivery b. Non-reassuring FHR (fetal distress) c. Dystocia may be due to (three Ps) relatively large fetus (passenger), small pelvis (passage) or insufficient uterine contractions (power) d. Antepartum hemorrhage e. Conjoint twins NOTE; Caesarean delivery on maternal request also can be done 11
  • 12. f. Malpresentation: Breech, or shoulder (transverse lie) g. Hypertensive disorders h. Medical-gynaecological disorders: (a) Diabetes (uncontrolled), heart disease (coarctation of aorta, Marfan’s syndrome; (b) mechanical obstruction (due to benign or malignant pelvic tumors (carcinoma cervix), or following repair of vesicovaginal fistula 12
  • 13.  Common indications of caesarean section for primigravidae • Failed indication • Fetal distress (non reassuring fetal FHR) • Feto-pelvic disproportion (CPD) • Dystocia ( nonprogress of labor) • Malposition and malpresentation (occipitoposterior, breech). 13
  • 14.  For, Mutigravidae, the followings are the common indications, • Previous caesarean delivery • Antepartum hemorrhage (placenta previa, placental abruption) • Malpresentation (breech, transverse lie) 14
  • 15. 15  Classifications • Based on timing at the time of decision making [RCOG2001) - Category 1:emergency-there's immediate threat to mother and fetus. Surgeryshould be within 30minutes - Category 2: urgent-fetal or maternal compromise not immediately life threateninge.g.,fetalheartrate abnormalities. Surgery should be within 1 hour
  • 16. 16 - Category 3: scheduled -mother needs early delivery but there is no compromise to either e.g.,failure to progress, pre- eclampsia with gradually worsening lab parameters. Surgery is planned for a few hours to a few days - Category4: elective- delivery is timed to suit mother and staff
  • 17. 17 • In 1996, Robson and co devised asystem of classification dividing all pregnant women using a maternity service into 10groups • This system has been adapted my several authorities with modification, including the WHO • This classification is used in assessing and comparing various health facilities on the basis of modes of delivery • The system uses 5 parameters, viz: - Obstetric history [parity, previous c/s} - Onset of labor [spontaneous, induced] - Lieandpresentation - Number of fetuses - Gestational age [term, preterm]
  • 18. 18
  • 19. 19
  • 20. 20
  • 21. 21
  • 22. 22
  • 23. 23
  • 24. 24
  • 25. 25
  • 26. 26
  • 27. 27
  • 28. TYPES OF OPERATION: There are two types of operations; 1. Lower segment 2. Classical or upper segment 28
  • 29. 1. Lower segment. • In this operation, the extraction of the baby is done through an incision made in the lower segment through a transperitoneal approach. • It is the only method practiced in present day obstetrics, and unless specified, caesarean section means lower segment operation. 29
  • 30. 2. Classical or upper segment • In this operation, the baby is extracted through an incision made in the upper segment of the uterus. 30
  • 31. LOWER SEGMENT CESAREAN SECTION (LSCS) Preoperative preparation. • Obtain informed consent; Informed written permission for the procedure, anaesthesia and blood transfusion is obtained. • For elective cases, patient should fast as follows 2 hours from clear fluids, 6hoursfromlightmeal, 8 hours from regular meal 31
  • 32. 32 • Abdomen is scrubbed with soap and nonorganic iodide lotion. • Premedicative sedative must not be given • Nonparticulate antacid (0.3 molar sodium citrate, 30 mL) is given orally before transferring the patient to theatre. It is given to neutralize the existing gastric acid. • Anaesthesia mostly regional (epidural or spinal) also general anaesthesia in some cases
  • 33. 33 • Lab investigations - FBC, Cr, clotting profile, urinalysis - Screen for transmissible diseases - Group and cross match blood • Imaging studies to confirm lie, presentation, placentation • Before taking patient to theatre -urinary catheter - antiacid -antibiotic prophylaxis (gentamycin and clindamycin, ceftriaxone if c/s last >3hrs the an additional doses is needed
  • 34. Position • Supine position in 15 degree left lateral tilt 34
  • 35. 35  Abdominal preparation - Used to include shaving maternal abdomen the night before surgery - Current recommendation is to shave in the theatre,just beforeskin preparation - Shaving the night before actually increases the bacterial count on the maternal abdomen - Shave only hairs that physically interfere with the procedure itself - Thereisnoreasontoshaveformostof thepatients
  • 36. 36  Skin preparation: the Association of Surgical Technologists, AST, recommendations amongst others, [WEF 2008] I. Patient to bathe or shower the night before surgery with an antiseptic,chlorhexidine gluconate, CHG II. Alcohol is anaccepted antiseptic agent, but should not be used asasingle agent III. Contaminated areasrequirespecial attention andshould be prepped last
  • 37. 37 Surgical Safety Check-list  Briefing-beforeinductionofanaesthesia - Anaesthesia equipment safety check - Confirm patient information - Review final test results - Confirm essential imaging displayed - ASAclass - Allergies -Medication
  • 38. 38 - Venous thromboembolism prophylaxis - Difficult airwayIAspiration risk - Monitoring devices - Anticipated blood loss - Reviews-surgeon(s), anesthesiologist(s), nurse(s) - Patient positioning and support - Expected procedure time /Post-Op destination
  • 39. 39 • Time out -Before skin incision - Team members introduce selves by name and role - Team members verbally confirm 'brief' - "Does anyone have any other questions or concerns before proceeding?
  • 40. 40 • Debriefing -Before patient leaves theatre - Surgeon and team members review • Procedure • Important intra-op events • Fluid balance - Anesthesiologist and team members review • Important intra-op events • Recovery events
  • 41. 41 • Debriefing-Beforepatient leavestheatre - Nurse(s) and team members review • Instruments IspongeIneedlecounts • Specimen labelling and management • Important intra-op events
  • 42. 42 Procedure • Involves the following steps - Laparotomy - Hysterotomy - Delivery of the fetus and placenta - Uterinerepair - Closure
  • 44. 44
  • 45. 45  Laparotomy - Approximate length of 15 cm or more - Excision of previous scar is essential for better results and cosmetic appearance - Includes the following • Midline infraumbilical [longitudinal] • Maylard [ transverse] • Joel-Cohens [transverse] • Pfannenstiel [ transverse] • paramedian [longitudinal]
  • 46. 46 • Midline infraumbilical - Provides quicker access to the uterus - Associated with less blood loss - Gives good exposure to abdominal and pelvic organs - The rectus sheath is either incised along the length with a scalpel, or a small incision is made and extended with scissors - Peritoneum is entered at thesuperior aspect of the incision to avoid bladder injury - Wound dehiscence due to low blood supply
  • 47. 47 • Paramedian - Used if classical c/s is contemplated - The upper 1/3rd is above the umbilicus - The lower 2/ 3rd is below the umbilicus
  • 48. 48 • Pfannenstiel - A transverse incision 3 cm above the symphysis pubis, curved slightly cephalad - Extends slightly beyond the lateral borders of the rectus muscle bilaterally y and carried to the fascia - The fascia's is incised bilaterally along thefull length of the incision - Underlying rectus muscles separated from the fascia both superiorly and inferiorly with blunt and sharp dissection - Rectus muscle separation
  • 49. 49 • Maylard - Made 2-3 cm above the symphysis pubis - Involves transverse incision of the anterior rectus sheath bilaterally and the medial 2/3rd of the rectus muscles are divided bilaterally - Thesuperficialinferior epigastricvessels are identified and ligated bilaterally - Transversalis faciaand peritoneum are identified andincised transversely - Gives better access and quicker than Pfannenstiel
  • 50. 50 • Joel-Cohens - A straight transverse incision made 3 cm below a linejoining the anterosuperior iliac spines - Incision is carrieddown to the anterior sheath of the rectus fascia - 3-4 cm incision is made here and bluntly opened by stretching in a craniocaudal fashion - Therectus muscles areretracted laterally and parietal peritoneum bluntly opened by digital dissection
  • 51. 51 • Transverse [vs longitudinal] : - Takeslightly longer to enter the peritoneal cavity - Are less painful - Have with less risk of developing incisional hernia - Pref erred cosmeticallyy - Preferred whenoperating on theobese Limits view of the upper abdomen Cannot be further extended if needed Less risk of fever
  • 52. 52
  • 53. 53 • Access the degree of rotation by palpation. It's commonly dextrorotated • Retract the bladder • Pack theparacolic gutters
  • 54. • Hysterotomy - Low transverse [Kerr] - Low vertical [De Lee] - J-shaped - U-shaped - Inverted T - Classical
  • 55. 55  Low transverse [Kerr] • Less incisional site bleeding • Easier to repair • Relatively non contractile portion • Healing better • Risk of uterine rupture in subsequent pregnancy <0.2-0.9%
  • 56. STEP 1;The loose peritoneum above the bladder reflection is grasped with forceps and incised with Metzenbaum scissor 56
  • 57. STEP 2 ;This peritoneal edge is elevated and incised laterally 57
  • 58. Cross section shows blunt dissection of the bladder off the uterus to expose the lower uterine segment. 58
  • 59. STEP3; the myometrium is incised with shallow strokes to avoid cutting the fetal head. 59
  • 60. STEP4; After entering the uterine cavity, the incision is extended laterally with fingers or with bandage scissors (inset). 60
  • 61. 61
  • 62. 62
  • 63. 63 • Low vertical [De Lee] - Indicated in poorly formed LUS, such as in preterm deliveries - They avoid the uterine arteries bilaterally - A trial of labor is possible in subsequent pregnancies - Risk of uterine rupture in subsequent pregnanciesis less than 1.5%[5] - Requires extensive bladder dissection to keep the incision 10-12 cm in the LUS - There may be an unwanted extension of the incision towards the bladder
  • 64. 64 • J-Shaped - Used in difficult situations that may require extension of a transverse incision to the upper segment - The extension is made on the most accessible part of the uterus - There is a greater risk of uterine rupture is subsequent pregnancies - Increases the duration of surgery - Example is shoulder impaction mistaken for breech
  • 65. 65 • U-Shaped - Indicated in the delivery of an impacted fetal head - Has more room bilaterally than the Kerr incision - Incision is made with a broad base, the convexity towards the pelvis and the ends cephalad - Less risk of lateral extension and injury to uterine vessels
  • 66. 66 • Inverted T - Similar indication as for J-Shaped incision - Both are associated with more blood loss
  • 67. 67 • Classical - Incision is made 10 cm on the anterior surface of the uterus - Should be done quickly because of the risk of hemorrhage is greater - Risk of cutting the fetus is greater than in all the afore mentioned - Delivery should be by breech extraction
  • 68. 68 • Classical [indications] - Transverse lie with back down, ruptured membranes and hand prolapse - Large fibroids in the LUS - Preliminary to caesarean hysterectomy - Very thin previous classical scar - Preterm breech with ruptured membranes - Extreme prematurity, before of the LUS (LUS not formed) - Dense adhesions in LUS - Cancer of the cervix - Morbidly adherent placenta in the LUS especially anterior located placenta
  • 69. 69 • Classical [advantages] - Rapid entry into the uterus - No lateral extension into the vessels of the broad ligaments - Easy entry into the uterus when there is fibroids in the lower uterine segment
  • 70. 70 • Classical [disadvantages] - Increased intra-op blood loss - High risk of adhesion formation - High risk of uterine rupture in subsequent pregnancies 2-9% - Less chance of VBAC
  • 71. 71
  • 72. 72 • Delivery of the baby [breech] - Manipulate feet to uterine incisionand deliver by extraction - Deliver arms and head, maintaining flexion of the head • Delivery of the baby [transverse] - Convert to cephalic and deliver
  • 73. 73 • Special situations - Bandl's [pathological retraction] ring • Incise through the ring • IV nitroglycerin may be used to relax uterus - Anterior placentaprevia • Insinuate thehand between the uterine walls and placenta to reach the membranes and quickly deliver the baby
  • 74. • The cord is cut in between two clamps and the baby is handed over to the pediatrician. The Doyen’s retractor is reintroduced. • The optimum interval between uterine incision and delivery should be less than 90 seconds. Interval > 90 seconds are associated with poor Apgar scores. There is reflex uterine vasoconstriction following uterine incision and manipulation. 74
  • 75. 75 • Delivery of the placenta - Cord traction - Manual delivery - Spontaneous expulsion
  • 76. 76
  • 77. Removal of the placenta and membranes: • By this time, the placenta is separated spontaneously. The placenta is extracted by traction on the cord with simultaneous pushing of the uterus towards the umbilicus per abdomen • using the left hand (controlled cord traction). Routine manual removal should not be done. Advantages of spontaneous placental separation are: less blood loss and less risk of endometritis. 77
  • 78. • The membranes are carefully removed preferably intact and even a small piece, if attached to the decidua should be removed using a dry gauze. • Dilatation of the internal os is not required. Exploration of the uterine cavity is desirable. 78
  • 79. 79 • Closure - Inspect pelvis and exclude injury to adjacent organs - Remove any clots seen or any instrument and gauzes - Irrigation may or may not be performed - Noneed to reapproximate theperitoneum ormuscle - Close the rectus sheath with PGA or nylon 1 - Close subcutaneous tissue if >2 cm
  • 80. • First layer: The first stitch is placed on the far side in the lateral angle of the uterine incision and is tied. The suture material is No “0” chromic catgut or vicryl and the needle is round bodied. • A continuous running suture taking deeper muscles excluding or including the decidua (very difficult to exclude) ensures effective apposition of the tissues; the stitch is ultimately tied after the suture includes the near end of the angle 80
  • 81. 81
  • 82. 82
  • 83. Second layer: • similar continuous suture is placed taking the superficial muscles and adjacent fascia overlapping the first layer of suture. Uterine muscles may be closed using a continuous single layer stitch taking full thickness muscle and decidua. • There is controversy as regard the place of single layer or double layer closure in relation to the risk of subsequent scar rupture. The peritoneal flaps may be apposed by continuous inverting suture (to prevent any raw surface). 83
  • 84. • Closure of rectus sheath by continuous suture • Subcutaneous fat can be sutured in obese but it is not required mostly • Skin closure by simple interrupted suture or sub Q • Occlusive dressing • Vaginal toileting 84
  • 85. 85  Postoperative care • Vital signs every 15 min for the first 1-2 hours • Urine output monitoring hourly • Palpate uterus to ensure it feels firm • Any active bleeding par vagina? • Ensure adequatepain control • Fluidmanagement3-4Linthefirst24hourspost op • Remove catheter after 12-24 hours
  • 86. 86 • Oralsips may bestarted within 12-24 hours and advanced accordingly • Encourage early ambulation by 151 post-op day • Encourage early initiation of breastfeeding if patient plans to breastfeed • Post-op PCV check by 151 post-op day • Patient may be discharged by day 3-4 if no complication • Oxytocic's: Injection oxytocin 5 units IM or IV (slow) or methergine 0.2 mg IM is given and may be repeated.
  • 87. • Prophylactic antibiotics; (cephalosporins, metronidazole) for all caesarean delivery is given for 2–4 doses. Therapeutic antibiotic is given when indicated. • Analgesics; in the form of pethidine hydrochloride 75–100 mg is administered and may have to be repeated 87
  • 88. • Baby is put to the breast for feeding after 3–4 hours when mother is stable and relieved of pain. • Day1: Oral feeding in the form of plain or electrolyte water or raw tea may be given. Active bowel sounds are observed by the end of the day. 88
  • 89. • Day2: Light solid diet of the patient’s choice is given. Bowel care: 3–4 teaspoons of lactulose is given at bed time, if the bowels do not move spontaneously • Day 5 or day 6: The abdominal skin stitches are to be removed on the D-5 (in transverse) or D-6 (in longitudinal).. 89
  • 90. Discharge: • The patient is discharged on the day following removal of the stitches, if otherwise fit. • Usual advices like those following vaginal delivery are given. Depending on postoperative recovery and availability of care at home, patient may be discharged as early as third to as late as seventh postoperative days 90
  • 91.  Complications of caesarean sections. Intraoperative complications. • Extension of uterine incision to one or both the sides • Uterine lacerations at the lower uterine incision • Bladder injury; is rare in a primary CS but may occur in a repeat procedure. • Ureteral injury is rare (1 in 1,000 procedures). Injury occurs during control of bleeding from lateral extensions. 91
  • 92. • Gastrointestinal tract injury is rare unless there is prior pelvic/abdominal adhesion • Hemorrhage may be due to uterine atony or uterine lacerations. Medical management should be started. 92
  • 93. Postoperative complications • Can be immediate or remote Immediate; • Postpartum hemorrhage • Shock • Anesthetic hazards • Infections • Intestinal obstruction 93
  • 94. • Deep vein thrombosis and thromboembolic disorders. • Wound complications, 94
  • 95. Remotes; • Gynaecological: Menstrual excess or irregularities, chronic pelvic pain or backache. • General surgical: Incisional hernia, intestinal obstruction due to adhesions and bands. • Future pregnancy: There is risk of scar rupture. 95
  • 96. VAGINAL BIRTH AFTER CESAREAN (VBAC) DELIVERY AND TRIAL OF LABOR AFTER CESARIAN(TOLAC) Vaginal birth after caesareans section Term applied to women who undergo vaginal delivery following caesarian delivery in a prior pregnancy Trial of labor after caesarean; Is a planned attempt to labor by a woman who has previously undergone caesarean delivery and desire subsequent vaginal delivery 96
  • 97. Few issues in modern obstetrics' have been as controversial as management of the women who has had a prior caesarean delivery For many decades a scarred uterus was believed by most to contraindicate labor out of fear of uterine rupture In 1916 Cragnin made his famous quotation and now seemingly excessive pronouncement “once a caesarean always a caesarean” 97
  • 98. In 1920s the technique of low transverse uterine incision was introduced by Kerr A large number of women may have successful and safe vaginal birth after c/s with reported figures of 70% to 80% (flamm etal 1990) American College of Obstetricians and Gynecologist concurs and states “most women with one previous c/s with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC 98
  • 99. 99
  • 100. Selection criteria for VBAC-TOLAC • Informed consent of the woman • One or two previous lower segment transverse scar • Nonrecurring indication for prior caesarean section • Vertex presentation( cephalic) • singleton • Availability of resources (anaesthesia, blood transfusion and theatre) for emergency caesarean section within 30 minutes of decision 100
  • 101. Pregnant women with a previous caesarean section can deliver in one of the following ways Trial of labor after previous caesarean delivery ending in vaginal birth Trial of labor after previous caesarean delivery ending in emergency caesarean section Planned elective repeat caesarean section NOTE; TOLAC should be undertaken in facilities with staff immediately available to provide emergency care 101
  • 102. Some factors that influence a successful trial of labor in a woman with prior caesarean delivery  Type of prior uterine incision  Prior uterine rupture; Women who have previously sustained a uterine rupture are at greater risk for recurrence. As shown in Table 31-3, those with a previous low-segment rupture have up to a 6-percent recurrence risk, whereas prior upper segment uterine rupture confers a 9- to 32-percent risk (Reyes-Ceja, 1969; Ritchie, 1971) 102
  • 103. 103
  • 104. 104 Interdelivery interval Magnetic resonance imaging studies of myometrial healing suggest that complete uterine involution and restoration of anatomy may require at least 6 months (Dicle, 1997) Stamilio and associates (2007) noted a threefold augmented risk of uterine rupture in women with an interpregnancy interval. So ideal time is at least 18 months
  • 105. 105  Closure of prior incision; A metanalysis by Roberge and colleagues (2014) compared single- versus double-layer closure and locking versus unlocking suture for uterine closure They reported that rates for uterine dehiscence or uterine rupture for these closures did not differ significantly.
  • 106. 106
  • 107.  Prior vaginal delivery Either before or after a caesarean birth, improves the prognosis for a subsequent vaginal delivery with either spontaneous or induced labor (Aviram, 2017; Grinstead, 2004; Hendler, 2004; Mercer, 2008). Prior vaginal delivery also lowers the risk of subsequent uterine rupture and other morbidities (Cahill, 2006; Hochler, 2014; Zelop, 1999) 107
  • 108. 108 Prior second-stage caesarean delivery can be associated with second-stage uterine rupture in a subsequent pregnancy (Jastrow, 2013).
  • 109. 109
  • 110.  Multifetal gestation • Twin pregnancy does not appear to increase the risk of uterine rupture with VBAC • Ford and associates(2006) analyzed the outcomes of 1850 such women with a prior caesarean delivery who attempted a trial of labor . The uterine rupture rate was 0.9% and the rate of successful vaginal delivery was 45% • Cahill(2005) and Varner (2007) and their colleagues reported ruptures of 0.7 to 1.1 percent and vaginal delivery rate of 75 to 85 % 110
  • 111. Maternal obesity Obesity decrease the success of VBAC Hibbard and colleagues(2006) reported the following vaginal delivery rates: 85% with a normal body mass index , 78% with a BMI between 25 and 30, 70%with a BMI between 30 to 40, and 61 %with a BMI of more than 40or more 111
  • 112.  Antenatal care Counseling regarding mode of delivery should ideally start at the time of the sentinel caesarean Women should be offered information regarding the need for the first caesarean and implication if may have for future pregnancies and deliveries Identify, at the first antenatal visit all women who have had a previous caesarean section or have a uterine scar a senior consultant should anesthesiologist 112
  • 113. Factors to note at the booking visit include Number and type of previous uterine scars, indications for prior c/s there any puerperal complications, gestation at time of prior c/s interconception interval and other associated medical complication Anticipated family size: this is important as the longer term risks related to further repeat c/s may be taken into consideration (placenta previa, placenta accreta, blood loss, transfusion, hysterectomy and mortality History of a successful vaginal delivery and whether this was before or after the uterine scar. The rupture rate rises with each successive labor but a prior vaginal delivery also increases the chances of a successful VBAC attempt 113
  • 114. • Antenatal counseling • Women with prior history of on uncomplicated LSCS, in an otherwise uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of planned VBAC and the alternative on an elective repeat c/s • The antenatal counselling of women with a prior c/s birth should be documented in the notes. A patient information leaflet should be provide with the consultation • A final decision fore mode of delivery for mode of birth should be agreed between the woman and her obstetrician before the expected /planned delivery date, ideally by 36 weeks of gestation • Placenta previa/accreta should be excluded with USG. Identifying and treating anemia early on is important in these women 114
  • 115. • If decision is made for TOLAC, the woman should be advised • To present to the obstetric unit early in labor • That the decision made in the antenatal clinic is not binding • To have a clear understanding with the obstetric team which states the boundaries of safe practice to which they have agreed and indicate the circumstances under which they would request that a repeat c/s be carried out • The decision should be clearly documented in the antenatal records 115
  • 116. Candidates for a TOLAC Some factors for consideration in selection of candidates for vaginal birth after caesarean delivery • One previous low transverse caesarean delivery • Clinically adequate pelvis • No other uterine scars or previous rupture • Physician immediately available throughout active labor capable of monitoring labor and performing an emergency caesarean delivery • Availability of anaesthesia and personnel for emergency caesarean delivery 116
  • 117. 117
  • 118. 118
  • 119. Contraindications for VBAC-TOL • Previous classical or inverted T-shaped uterine incision ;uterine incision that has involved the whole length of the uterine corpus(200-900/10000 incidence) • Previous two or more lower segment caesarean section • Pelvis contracted or suspected feto-pelvic disproportion • Presence of other complications in pregnancy: Obstetric (preeclampsia, malpresentation, placenta previa) or medical • Resources limited for emergency caesarean delivery 119
  • 120. … • patient refusal for VBAC-TOL • History of prior uterine rupture ;risk of recurrent rupture is unknown • Blood in urine • Tenderness of the scar • Meconium stain • Fetal tachycardia 120
  • 121. 121 Intrapartum Management Women who have had a previous caesarean section should be offered care during labor in a unit where:  There is immediate access to caesarean section.   There are on site blood transfusion services or blood can be obtained with in a reasonable amount of time.   Facilities for continuous fetal heart monitoring are available, preferably electronic fetal heart monitoring.   Specialist obstetricians, anesthetists and pediatrician are available round the clock
  • 122. 122 Continuous fetal monitoring • Continuous electronic fetal monitoring is recommended following the onset of uterine contractions for the duration of TOLAC. • An abnormal CTG is the most consistent finding in uterine rupture and is present in 55% to 87% of these events(guise et al 2004) • Partogram for progress of labor;Partographic progress of labor enhances safety. A partogram, in addition to monitoring progress of labor, enables effective monitoring of maternal parameters like blood pressure and pulse rate. • The duration of labor should be closely monitored with special reference to alert and action line on partogram. Prolongation of labor is an important sign of dystocia
  • 123. 123 Analgesia • Epidural analgesia for labor may be used as part of TOLAC, and adequate pain relief may encourage women to choose TOLAC (sakala et al 1990, flamm et al 1998). • In addition effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture, particularly because the most common sign of rupture is FHR tracing abnormalities.
  • 124. 124 Early diagnosis of uterine rupture Early diagnosis of uterine scar rupture followed by expeditious laparotomy and resuscitations essential to reduce associated morbidity and mortality and infants. There is no single pathognomonic clinical feature that is indicative of uterine rupture but the presence of any of the following peripartum signs and symptoms should raise the concern of the possibilities of uterine rupture (turner 2002) Abnormal CTG tracing, severe abdominal pain persisting in between contractions, chest pain or shoulder tip pain, acute onset scar tenderness, abnormal vaginal bleeding and hematuria, cessation of previously efficient uterine activity, maternal tachycardia, hypotension or shock, loss of station of the presenting part.
  • 125. 125 Delivery The length of the second stage should not exceed 2 hrs. one hour to allow passive descent, but no more than one hour for active pushing (or 30 minutes if the woman has had a prior vaginal delivery). Assisted delivery in the presence of a prior uterine scar, should ideally only be performed by an experienced consultant. This should be in the operating theatre with provision for immediate caesarean section. Excessive vaginal bleeding or signs of hypovolemia are potential signs of uterine rupture and should prompt complete evaluation of the genital tract (cahill etal 2005)
  • 126. 126 Role of induction and augmentation of labor in VBAC Women with a previous caesarean should be informed of the two to three fold increased risk of uterine rupture and around 1.5 fold increased risk of caesarean section in induced labors compared with spontaneous labor.2 Lydon-Rochelle and associates (2001) performed a retrospective population-based study. They found that induction of labor with prostaglandins for VBAC increased the uterine rupture risk more than 15-fold compared with elective repeat caesarean delivery.1
  • 127. Benefit for VBAC-TOLAC • Decreased maternal morbidity (infection and others) • Reduced length of hospital stay • Decreased need for blood transfusion • Decreased risk of abnormal placentation • Decrease need for successive caesarean delivery in next pregnancy 127
  • 128. Complications of Unsuccessful VBAC-TOL Maternal Uterine wound dehiscence  Uterine rupture (0.5–1%) ;the most common sign of uterine rupture is a nonreassuring fetal heart rate pattern with variable decelerations that may evolve into late decelerations and bradycardia, hemoperitoneum from a ruptured uterus may result in diaphragmatic irritation with pain referred to the chest.  With rupture, the only chance of fetal survival is afforded by immediate delivery—most often by laparotomy—otherwise, hypoxia is inevitable. If rupture is followed by total placental separation, then very few neurologically intact fetuses will be salvaged. Thus, even in the best of circumstances, some fetal outcomes will be impaired. 128
  • 129. 129 Increased blood transfusion Increased risks of hysterectomy due to uterine rupture Infections, increased maternal morbidity
  • 130. … Perinatal: • Low Apgar score, • admission to NICU, • hypoxic ischemic encephalopathy (HIE), • neonatal death, rarely stillbirth 130
  • 131. References 131 • Hiralal Konar (2015-05-10) DC Dutta's Textbook of Obstetrics. JP Medical Ltd. • F. Gary Cunningham, Kenneth J. Leveno, Jodi S. Dashe, Barbara L. Hoffman, Catherine Y. Spong, Brian M. Casey (2022-04-05) Williams Obstetrics 26e. McGraw Hill Professional. • caesarean delivery. [Online] Available at: https://www.slideshare.net/imezi/caesarean-delivery?from_search=4 [Accessed: 24 March 2024] • Philip N. Baker, Louise Kenny (2011-03-25) Obstetrics by Ten Teachers, 19th Edition. CRC Press.