Post lscs pregnancy
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Transcript of Post lscs pregnancy
POST CESAREAN PREGNANCY
Dr Nilam Dixit
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]
Cesarean Section [CS] - Indications1) Labour dystocia – Arrest of cervical dilatation
or arrest of foetal descent2) Breech presentation – Malpresentation3) 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
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
Effects On Pregnancy And Labor
• Increases risk ofAbortionPreterm laborPregnancy ailmentsOperative interferencePlacenta praeviaAdherent placentaPost partum hemorrhagePeripartum hysterectomy
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
04/17/2023 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 %
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Previous Uterine Scar BehaviorLSCS [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]
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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
04/17/2023 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]
PREVIOUS SCAR
Dehiscence-separation along the line of the previous scar
Rupture – when the unscarred
tissue is also involved in separation
1. Elective caesarean section
2. VBAC trial of labor (trial of scar)
Management
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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
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VBAC – Selection Criteria
1. H/O one previous lower segment transverse caesarean section
2. Maternal pelvis is clinically adequate3. No H/O previous rupture of uterine scar4. Facilities for continuous and strict labour
monitoring available5. Availability of USG, operating team, operation
theatre and compatible safe blood
– 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
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Uterine Scar rupture - Symptoms
1. Supra pubic pain – in between uterine contractions2. Unexplained vaginal bleed3. Frequent urge to pass urine4. Presence of hematuria
04/17/2023 hcb 18
Uterine Scar Rupture - Signs
1. Maternal tachycardia and hypotension2. Foetal heart variability [decelerations]3. Uterine scar tenderness4. Failure of progress of labour [arrest of descent
of foetal parts]
04/17/2023 hcb 19
Controversies in VBAC
1. Use of oxytocin for induction or augmentation of labour – increase incidence of uterine scar rupture2. Use of epidural anaesthesia – masks the pain of uterine rupture and can cause FHR decelerations3. Examination of uterine scar after VBAC
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
THANK YOU