1. The document discusses post-cesarean pregnancy and management options. Women with a previous cesarean section have an increased risk of complications during subsequent pregnancies like scar rupture or dehiscence. 2. Trial of vaginal birth after cesarean (VBAC) can be attempted if the first cesarean section was low transverse and facilities for emergency cesarean are available. Risk factors like classical or inverted-T incisions or medical complications contraindicate VBAC. 3. Close monitoring during labor is needed for VBAC due to risks of uterine rupture which can be life-threatening for the mother and baby if not recognized promptly. Elective repeat cesarean is recommended if VB

1. POST CESAREAN PREGNANCY
Dr Nilam Dixit

2. POST CESAREAN PREGNANCY
• Pregnancy with history of previous caesarean
section
• Caesarean section rate – 8 to 25%
[Increase in the incidence of CS rate is
because of liberal and expanded
indications]

3. Cesarean Section [CS] - Indications
1) Labour dystocia – Arrest of cervical dilatation or
arrest of foetal descent
2) Breech presentation – Malpresentation
3) Foetal distress – Foetal heart abnormalities,
Hypoxia/ Acidosis and Meconium stained
liquor [MSL]
4) Previous caesarean pregnancy
5) Others – APH [Accidental haemorrhage and
Placenta praevia], Severe PIH and IUGR

4. Why Increase in CS Rate?
1) Increase in maternal age and decrease in parity
(precious baby)
2) Electronic foetal monitoring – FHR decelerations
3) Breech presentation – primigravidas with breech
presentation are taken up for Elective CS
4) Increased Litigations

5. Effects On Pregnancy And Labor
• Increases risk of
Abortion
Preterm labor
Pregnancy ailments
Operative interference
Placenta praevia
Adherent placenta
Post partum hemorrhage
Peripartum hysterectomy

6. Effects On The Scar
• Increased risk of scar rupture
• More risk in classical/ hysterotomy scar
than lower segment scar
• Lower segment scar rupture during labor
• Classical/ hysterotomy scar ruptures
during late pregnancy and labor
• Impairment of healing can cause early scar
rupture

7. 6/7/2015 hcb 7
Type and Incidence of Scar Rupture
S.No Type of Scar Incidence of scar
rupture
1 Upper segment –[Classical] 4 – 9 %
2 Lower segment:-
a Low vertical 1 – 7 %
b* Low Transverse [LSCS] 0.2 – 1.5 %
3 T – shape scar 4 – 9 %

8. 6/7/2015 hcb 8
Previous Uterine Scar Behavior
LSCS [Lower segment
Transverse Scar] –
1.Thin margins – better
apposition
2.Suture line undisturbed –
passive segment [stretch
and relax]
Classical [Upper segment
Vertical Scar] –
1.Thick margins - apposition
unsatifactory
2. Loosening of sutures – active
segment [contract and
retract]

9. 6/7/2015 hcb 9
Previous Uterine Scar Behavior - contd
• Transverse Scar –
3. Stretching of scar is
along the line of
incision during
pregnancy and labour
4. Placental implantation
over scar – less chances
• Vertical Scar –
3. Stretching of scar is
right angle to the line of
incision
4. Placental implantation
over scar – More
chances

10. 6/7/2015 hcb 10
Previous Uterine Scar Behavior - contd
• Transverse Scar –
5. Scar rupture rate:- 0.2 to
1.5% [Sound scar, scar
ruptures during labour and
less incidence of maternal
& foetal mortality]
• Vertical Scar –
5. Scar rupture rate: 4 to 9%
[Weak Scar, scar ruptures
during pregnancy and
labour; more incidence of
maternal & foetal
mortality]

11. PREVIOUS SCAR
 Dehiscence-
separation along the
line of the previous
scar
 Rupture –
when the unscarred
tissue is also involved in
separation

13. 1. Elective caesarean section
2. VBAC trial of labor (trial of scar)
Management

14. 6/7/2015 hcb 14
Vaginal Birth After Cesarean [VBAC]
• Rupture of uterus during pregnancy or labour
can be catastrophic, therefore VBAC should
be attempted in a well equipped institution
only
• Where services of Obstetrician,
Anaesthesiologist, Neonatologist are available
and safe blood can be transfused to the
patient if required

15. 6/7/2015 hcb 15
VBAC – Selection Criteria
1. H/O one previous lower segment transverse
caesarean section
2. Maternal pelvis is clinically adequate
3. No H/O previous rupture of uterine scar
4. Facilities for continuous and strict labour
monitoring available
5. Availability of USG, operating team, operation
theatre and compatible safe blood

16. – Previous classical incision
– Previous two LSCS
– Pelvis contracted or suspected CPD
– Previous inverted T/ extension of incision
– Malpresentations
– Suspicion of CPD
– Medical /obstetric complication
– Multiple pregnancy
– Patient’s refusal to undergo trial
Contraindications

17. 6/7/2015 hcb 17
Uterine Scar rupture - Symptoms
1. Supra pubic pain – in between uterine
contractions
2. Unexplained vaginal bleed
3. Frequent urge to pass urine
4. Presence of hematuria

18. 6/7/2015 hcb 18
Uterine Scar Rupture - Signs
1. Maternal tachycardia and hypotension
2. Foetal heart variability [decelerations]
3. Uterine scar tenderness
4. Failure of progress of labour [arrest of descent
of foetal parts]

19. 6/7/2015 hcb 19
Controversies in VBAC
1. Use of oxytocin for induction or
augmentation of labour – increase incidence
of uterine scar rupture
2. Use of epidural anaesthesia – masks the
pain of uterine rupture and can cause FHR
decelerations
3. Examination of uterine scar after VBAC

20.  If VBAC is contraindicated / if patient refuses
Timing
• if fetal maturity is sure  39wks
• if not  spontaneous labor awaited
• previous classical CS  38 wks
Elective cesarean section

21. THANK YOU