obstetrics. the process of Vbac and LSCS

1. LSCS &VBACKishore SR
Oman Medical College
Textbook of Obstetrics by Sheila Balakrishnan
Ch 53 & 37

2. Introduction
• Caesarean Section is a delivery of a viable
fetus through an incision in abdominal wall and
intact uterus.
• Most common operation performed worldwide.
• Primary Caesarean is the first CS to be done on
a patient, while Secondary Caesarean is the
repeat procedure.

3. Indications for Caesarean Section
• Previous C.S
• Dystocia or dysfunctional labour:
• Cephalopelvic disproportion
• Tumours complicating pregnancy
• Fetal macrosomia
• Malpresentations
• Deep transverse arrest
• Abnormal uterine action
• Failed forceps or vacuum
• Failed induction
• Fetal distress and cord prolapse

4. • Breech presentation (complicated breech and
footling presentation
• Other fetal indication
• Severe intrauterine growth restriction
• Multiple pregnancy
• Antepartum hemorrhage:
• Placenta praevia
• Abruptio placenta
• Vasa praevia
• Maternal problems:
• Elderly nullipara
• Prolonged period of infertility or pregnancy following
in vitro fertilization
• Bad obstetric history
• Severe preeclampsia and diabetes

5. • Caesarean Section on request.
Most Common Indications (85% of the cases)
• Previous CS (most common)
• Dystocia
• Fetal distress
• Breech Presentation

6. Lower Segment Caesarean Section
(LSCS)
• A lower (uterine) segment Caesarean section
(LSCS) is the most commonly used type of
Caesarean section used today.
• It includes a transverse cut just above the edge
of the bladder and results in less blood loss and
is easier to repair than other types of Caesarean
sections.
• The advantage is that the healing of the lower
segment is better as it is quiescent and high
tensile strength.

7. Preparing the patient for LSCS
• Cross matched blood
• Introduction of indwelling catheter
• Skin prepared by antiseptic solution and draped
• Prophylactic antibiotics to prevent puerperal
sepsis.
• Left lateral tilt to reduce aortocaval compression
and risk of supine hypotension.
• Thromboprophylaxis for high risk patients.
• Anesthesia, Regional is always better(spinal or
epidural)
• In emergency CS, prevention of Mendelson’s

8. Abdominal Incisions
• Pfannensteil Incision
▫ Most commonly used
▫ Transverse curvilinear incision just above the
pubic hairline.
• Joel Cohen Incision
▫ A modified transverse incision placed about 3 cm
below the line joining the anterior superior iliac
spines.
▫ Higher than the Pfannensteil incision & not
curved.
• Maylard Incision
▫ Where more exposure needed in a transverse

10. Procedure
• Uterine Incision
∙ Correct any dextrorotation
∙ Visualize the lower segment (Doyens retractor)
∙ Loose peritoneum is divided transversely and
separated from the bladder by blunt incision
∙ Small incision made in the lower segment and
extended laterally using scissors.

14. • Delivery of the Baby
• Hand slipped into the uterine cavity and head is
gently levered out.
• Fundal Pressure maybe exerted on fetal buttocks
• Mouth and nose are suctioned to prevent
aspiration and the rest of the body is delivered by
gentle traction.
• The umbilical cord is doubly clamped.
• LSCS Complete Video

15. • If the presentation is breech,
▫ The feet are hooked out.
▫ The rest of the baby delivered as in case of a
vaginal breech delivery.
▫ Breech delivery via LSCS
• Deeply Impacted head,
▫ The head may deeply impacted in midpelvis with
a thinned out lower segment.
▫ Patwardhan method can be used in deeply
impacted head.

16. • Transverse or Oblique lie,
▫ Corrected to a longitudinal lie before the uterine
incision is made.
• If transverse lie with ruptured membranes and
an undeveloped lower segment,
▫ Extension of the uterine incision may be needed
• In case of dorsoinferior position with rupture
membranes,
▫ More difficulty and this is one situation where a
transverse incision considered

17. • Closure of uterine incision
▫ Oxytocin infusion is started.
▫ Placenta and membranes are removed by controlled
cord traction.
▫ The uterine edges are held with Allis forceps or
green-Armytage forceps.
▫ The uterine incision is closed in two layers of
continuous suture
▫ It is important that the two angles and any other
bleeding points be securely ligated.
▫ Haemostasis is ensured.
▫ The tubes and ovaries are inspected.

19. • Closure of the Abdomen
▫ Closed in layers after confirming mop and
instrument count.
▫ The parietal peritoneum need not be closed.
▫ The rectus sheath is carefully approximated with
delayed absorbable sutures to minimize the
chance of wound dehiscence.
▫ The skin approximated with mattress sutures, a
subcuticular suture or clips.

20. Post Operative Care
• First 6-8hrs, monitor the vitals and look for
vaginal bleeding and condition of the uterus.
• First Day, paraenteral fluids are given, blood
transfusion if needed, antibiotics,
thromboprophylaxis, breast feeding after 4hrs &
oral fluid started after 6hrs.
• Second day, catheter and dressing removed and
early ambulation.
• Third day, light solid diet can be started & laxative
*if.

21. Other Types of Caesarean Sections
• Inductions: constricting ring, lower segment not
formed & prematurity
• Incision can extend downward (cervix , vagina,
bladder) & increased chance of rupture in next
pregnancy if incision extend to upper segment
Lower Segment Vertical
Incision
• Indications: Unapproachable lower segment,
cervix ca, ant placenta previa with previous CS,
some cases of transverse lie with ruptured
membrane & conjoined twins
• Healing is difficult, scar rupture is more in next
pregnancy
Classical Caesarean
Section
• Method of dealing with severe infectionExtraperitoneal
Caesarean Section
• Done as a life saving measures for severe atonic
PPH & ruptured uterus, adherent placenta,
multiple large myomas, severe sepsis and Ca in
situ of the cervix
Caesarean
Hysterectomy
• Emergency Cs in a women who has had a cardiac
arrest to save a live fetus
Perimortem Caesarean
Section

23. Complications
LATE SEQUELAEPOSTOPERATIVEINTRAOPERATIVE
Secondary PPH
Incisional hernia
Placenta previa &
adherent placenta in
next pregnancy
Vesicovaginal fistula
Scar rupture in next
pregnancy
Increased incidence of
Paralytic ileus
DVT and PE
Infections, Peritonitis
and Pelvic abscess
Wound dehiscence
Respiratory
complications
Pelvic thrombophlebitis
Primary hemorrhage
Injury to internal organs
Injury to baby
Difficulty in delivery of
head
Anesthesia
complications:
-Aspiration
-Mendelson’s syndrome
-Hypotension

24. Questions?
Q. All the following are indications for a
Caesarean section except
a) Abruptio placenta
b) Footling breech
c) Placenta Percreta
d) Untreated Stage 1 Carcinoma cervix
e) Active Genital herpes

25. Vaginal Birth After C-Section
(VBAC)
• Once A C-section is not always a C-section
• If the Patient had a cesarean delivery before,
she may be able to deliver your next baby
vaginally. This is called vaginal birth after
cesarean, or VBAC

26. Risks Involved
• Scar rupture
▫ More chance of rupture with a classical section
scar
• Adherent placenta
▫ Risk of morbid adherence of placenta increases
with each CS.
▫ Risk of severe PPH and caesarean hysterectomy
is increased
• Operative interference
• Peripartum hysterectomy

27. Management
• Elective Caesarean Section
• Trial of Labour after Caesarean (TOLAC)
▫ Ultrasound is of importance
▫ Myometrial thickness is 3.5mm or more there is
Low risk of uterine rupture.
▫ To assess placental location

28. Contraindications to VBAC
• Previous classical incision
• Previous two LSCS
• Previous inverted T incision
• Previous low vertical incision
• Malpresentations
• Cephalopelvic disproportion
• Multiple Pregnancy
• Patient’s refuse to undergo trial of labour

29. Selection of Cases
Previous History
• Type of incision
• Prior indication
• Prior vaginal delivery
• Interpregnancy interval
>6months
Present Pregnancy
• No medical or Obstetric
complications
• Vertex presentation
• Average sized baby
• No CPD
• Patient preference
Labour
• Institutional delivery
• Spontaneous onset of
labour
• Continuous CTG
• Emergency CS ready

30. Management
• Informed consent
• Monitoring
• Delivery
• Signs of Scar dehiscence
• If Intrauterine fetal demise,
▫ Oral mifepristone can be used alone for indication
of labour in this case