This document discusses management considerations for pregnancies following previous caesarean sections. It finds that pregnancies after a previous classical/hysterotomy scar carry a higher risk of uterine rupture compared to those with a previous lower segment transverse scar. For classical scars, an elective repeat caesarean is recommended at 38 weeks. Those with a previous lower segment scar can attempt a vaginal birth after caesarean (VBAC) if certain criteria are met, like a prior nonrecurring indication and adequate monitoring resources. Strict monitoring during labour is needed for all previous scar pregnancies to detect any signs of scar rupture.

1. CMC
Post caesarean pregnancy

2. Introduction
 Quite prevalent
 Liberalisation of primary CS
 Non recurrent indications
 Once a caesarean, always a caesarean

3. Effects On Pregnancy And
Labour
 Increases risk of
Abortion
Preterm labour
Pregnancy ailments
Operative interference
Placenta praevia
Adherent placenta
Post partum hemorrhage
Peripartum hysterectomy

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

5. Lower SEGMENT VS CLASSICAL/
HYSTEROTOMY SCAR
Lower Segment Classial /Hysterotomy
Apposition Perfect, no pockets of
blood
Difficult to appose
State of uterus during
healing
The part of uterus
remains inert
The part contracts and
retracts
Stretching effect Along the line of scar At right angles to scar
Placental implantation Attachment on scar
unlikely
Placenta more likely to
implant on scar
Net effect Sound scar Weak scar
Chances of rupture 0.2 - 1.5% 4 - 9%
Mortality following
rupture
Maternal and perinatal
death less
more

7. INTEGRITY OF THE SCAR
 CLASSICAL SCAR : The scar is weak. The scar
is more likely to give way during pregnancy with
increased risk to the mother and fetus. These
cases should be delivered by LSCS
 LOWER SEGEMENT TRANSVERSE SCAR:
Usually heals better. During the course of labour
the integrity of the scar need to be assessed.
High index of suspicion is essential. Factor that
are to be considered while assessing scar are:
evidences of Scar Dehiscence during labour.

8. Previous operative notes
 Indication of caesarean section: (a) Placenta
praevia – (i) imperfect apposition due to quick
surgery and (ii) thrombosis of the placental
sinuses. (b) Following prolonged labour-increased
chance of sepsis.
 Technical difficulty in the primary operation
leading to tears to involve the branches of uterine
vessels.

9. •Hysterography in interconceptional period:
Hysterography, 6 months after the
operation, may reveal defect on the scar
Pregnancy:
(1) Pregnancy occurring soon after
operation
(2)Pregnancy complication
(3)h/o previous vaginal delivery following
LSCS
(4)Placenta praevia in present pregnancy

10. Evidence of scar rupture during
labour
Abnormal CTG- most consistent finding
Suprapubic pain
Shoulder tip pain or chest pain or sudden
onset of shortness of breath
Acute onset of scar tenderness
Abnormal vaginal bleeding or haematuria
Cessation of uterine contractions which were
previously adequate
Maternal shock
Loss of station of presenting part

11. PROGNOSIS
Previous history of classical LSCS or
hysterotomy makes the women vulnerable
for uterine rupture.this can increase the
maternal mortality to 5% and perinatal
mortality to 75%

13. INVESTIGATIONS AND ASSESSMENT
 Mandatory regular antenatal checkup
 History of pain or tenderness over scar or any h/o vaginal bleeding
 ULTRASOUND :
1) To assess integrity of the scar.
(Myometrial thickness>3.5mm  NORMAL/low risk of uterine
rupture
2) To assess placental location
(absence of sub placental zone  adherent placenta)
- Doppler and MRI may be done for confirmation

14. ADMISSION AT
38 WEEKS
ADMISSION AT
36 WEEKSELECTIVE
HOSPITALIZATION
LOWER
SEGMENT
TRANSVERSE
SCAR
ELECTIVE
C.S.
VAGINAL
DELIVERY
CLASSICAL/
HYSTERECTOM
Y SCAR
ELECTIVE
C.S. AT 38
WEEKS
 CASE
ASSESSMENT
 FORMULATION
OF METHOD OF
DELIVERY

15. ONSET OF
LABOUR
SCAR RUPTURE
OBSTETRIC
COMPLICATIONS
EMERGENCY HOSPITALIZATION

16. MANAGEMENT FOLLOWING A:
PREVIOUS CLASSICAL CESAREAN SECTION : elective repeat section
as soon as the pregnancy reaches 38 weeks.
PREVIOUS LSCS
 Mandatory hospital delivery and individualization of the case
 Overall assessment is made with due consideration to:
 indication of primary cesarean section
 integrity of the scar
 associated obstetric complications
 number of previous cesarean sections
 estimated weight of the baby

17. VAGINAL BIRTH AFTER
PREVIOUS CAESAREAN
SECTION(VBAC)

18. VBAC-TOL
 Successful in 70-76% cases
PREDICTORS FOR SUCCESS:
 Prior nonrecurring indication
 Previous vaginal delivery
 Estimated foetal weight (lesser-higher success rate)
 Spontaneous onset of labour
 Cervical dilatation(on admission) >4cm
 Interpregnancy period > 2yrs.

19. SELECTION CRITERIA
 Previous LSCS-transverse scar
 Pelvis adequate
 Continued monitoring possible
 Availability of resources
 Informed consent

20. CONTRAINDICATIONS
 Previous classical/ T-shaped incision
 Previous uterine rupture
 Previous 2 or more LSCS
 Contracted pelvis
 Other complications
 Limited resources

21. MANAGEMENT OF LABOUR & DELIVERY
 Iv-Ringer soln
 Blood sample – Hb,group,cross matching
 Spontaneous onset of labour desired
 Monitoring
 Epidural analgesia
 Augmentation by oxytocin – selectively & judiciously
 Prophylactic forceps or ventouse
 Exploration of uterus.

22. BENEFITS COMPLICATIONS
Decrease-
 maternal morbidity
 hospital stay
 need for blood
transfusion
 risk of abnormal
placentation
 need for c-section in next
pregnancy
MATERNAL:
 Uterine rupture
 Risk of hysterectomy
 Infections
 Maternal morbidity
FOETAL:
 Foetal distress
 Low APGAR
 Death

23. THANK YOU!