Post LSCS Pregnancy Management protocols

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Post LSCS PregnancyManagement protocols
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• Dr. Geetha Balsarkar,
• Associate Professor and Unit incharge,
• Nowrosjee Wadia Maternity Hospital,
• Seth G.S. Medical college, Parel , Mumbai
• Joint Asst. Secretary to the Editor,
• Journal of Obstetrics and Gynecology of India,
• Secretary, AMWI, Mumbai branch

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Plan of Discussion

• Comparison of Trial of labour vs Planned Repeat
  Caesarean
• Selection of patients for VBAC
• Management of patients undergoing VBAC
• Check list for patients planned for Trial of
  labour

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Delivery Outcomes

• Planned repeat caesarean delivery (PRCD)
• - Maternal morbidity 3.6
• Trial of labour after caesarean
• Emergency repeat caesarean delivery (ERCD)
• - Maternal morbidity 14.1
• Vaginal birth after caesarean (VBAC)
• - Maternal morbidity 2.4

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Maternal Consequences of PRCD

• Anesthesia risks high spinal, Mendelsons
  syndrome, gastro intestinal symptoms
• ? risk of short term maternal morbidity
  increased bleeding, wound healing
• Placenta praevia in future pregnancies
• Morbid adhesions of placenta in future pregnancies

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Advantages of VBAC over PRCD

• ? febrile morbidity (OR 0.7)
• ? blood transfusion (OR 0.6)
• ? rates of Hysterectomy (OR 0.4)
• ? venous thrombo- embolism (OR 0.4)

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Neonatal Risks of PRCD

• Neonatal respiratory morbidity
• ? admission to NICU (7 vs 4.6 for attempted
  VBAC)
• Healthy cohort selection bias

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Neonatal / Fetal advantages of PRCD

• ? incidence of neonatal trauma, intra-cranial
  haemorrhage Hypoxic ischaemic encephalopathy
  (vs attempted VBAC)
• ? incidence of unexplained antepartum stillbirth

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Maternal Risks of VBAC

• Perineal / Vaginal lacerations
• Emergency caesarean delivery
• Uterine rupture
• PRCD 1.6 / 1000
• Spontaneous labour 5.2 / 1000
• Induction with oxytocin 7.7 / 1000
• Induction with prostaglandins 24.5 / 1000

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Long Term Maternal Consequences of VBAC

• Urinary incontinence (prevalence 21 vs 15.9 for
  PRCD)
• Uterovaginal prolapse

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Fetal / Neonatal Risks of VBAC

• Fetal death following uterine rupture
• Neonatal sepsis following failed VBAC
• ? incidence of perinatal death (OR 1.7) (Absolute
  risk 0.6)
• Women with a previous caesarean have a two to
  three fold ? incidence of unexplained stillbirth
  after 39 weeks gestation (Absolute risk 0.1)

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Risks of Failed VBAC

• Intra-operative injury during emergency LSCS
  (1.3 vs 0.6 for PRCD)
• Non significant trend towards increased maternal
  mortality

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Prediction of Success

• Maternal age
• Maternal obesity
• Indication of previous CS
• Previous vaginal delivery
• Gestational diabetes
• Birth weight
• Spontaneous or induced labour
• Progress in early labour

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Prediction of rupture

• Previous non lower segment incision
• Number of previous caesareans (2 3 fold
  increase in women with two previous caesareans as
  compared to only one previous caesarean)
• Previous rupture
• No previous vaginal birth
• Single layer closure (4 fold increase)
• Interval between previous caesarean and next
  pregnancy (3 fold increase with interdelivery
  interval lt 18 months)
• Use of prostaglandins (RR 4.7)

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Influence of Patient intentions

• Patient willingness to undergo VBAC (Informed
  consent)
• Future reproductive intentions

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Prerequisites to Attempting VBAC

• Obstetrician available continuously to monitor
  labour
• Availability of emergency anaesthesia, neonatal
  and blood banking services
• Availability of continuous electronic fetal
  monitoring
• Institutional capability of decision to incision
  interval of lt 30 minutes for performing emergency
  surgery

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Management During Attempted VBAC

• Absolute risk of uterine rupture 1100 to 1200
• Continuous electronic fetal monitoring
• Epidural analgesia is not contraindicated
• Use of Intra-uterine pressure catheters is not
  necessary
• Partogram to assess progress
• Oxytocin for augmentation to be used with caution
  and only for inadequate uterine activity
• Second stage to be shortened
• Exploration of the uterine scar after delivery
  not necessary

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CHECK LIST FOR SELECTING VBAC
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Are there any contraindications to VBAC ?

• Number of previous lower segment caesareans
• J shaped / Inverted T scar on uterus
• A scar other than on the lower uterine segment
• Past H/O uterine rupture / dehiscence of scar
• Presence of an obstetric indication for LSCS
• Doubtful adequacy of the pelvis / suspicion of
  feto-pelvic disproportion
• Institutional policy on induction of labor in a
  scarred uterus
• Lack of capability to provide continuous
  supervision during trial of labour
• Lack of institutional capability to undertake
  expeditious operative delivery

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Assessment of prognostic factors for a successful
VBAC

• Indication of previous caesareans (Dystocia / Non
  dystocia)
• Past H/O vaginal birth
• Maternal age
• Maternal obesity
• Post datism
• Station and attitude of vertex
• Favourability of cervix
• Spontaneous or induced labour

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Assessment of Prognostic Factors for Uterine
Rupture During Trial of Labour

• Unknown uterine scar
• Uterine closure during previous caesarean (Single
  / Double layer closure)
• Post operative recovery following previous
  caesarean
• Inter delivery interval
• Fetal macrosomia
• Thickness of the lower uterine segment (if
  possible to assess)
• Spontaneous or induced labour
• Delay in progress of labour
• Augmentation of labour

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Patients intention

• Informed consent

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Thank you