Prior cesarean delivery (VBAC)

previous cesarean delivery, source- Williams and RCOG
VBAC

1. Previous cesarean delivery Dr NISHMA BAJRACHARYA FCPS 1 ST YR RESIDENT OBS/GYNE

2. Once a cesarean, always a cesarean. Cragin , 1916 Once a cesarean, always a trial of labor? Pauerstein , 1966 Once a cesarean, always a controversy . Flamm , 1997

3. Elective repeat cesarean Delivery (ERCD) – Also called ERCS (Elective Repeat Cesarean Section) Trial of labor after cesarean (TOLAC) This can have 2 outcomes Successful TOLAC – Vaginal Birth After Cesarean Delivery Failed TOLAC - Emergency cesarean Delivery Options for a patient with previous cesarean

4. Which women are best suited to have a planned VBAC? Planned VBAC is appropriate for and may be offered to the majority of women with a singleton pregnancy of cephalic presentation at 37+0 weeks or beyond who have had a single previous lower segment caesarean delivery, with or without a history of previous vaginal birth. RCOG October 2015

5. Planned VBAC ERCS Maternal outcome 72–75% chance of successful VBAC Able to plan a known delivery date in select patients. ~ 0.5% risk of uterine scar rupture avoids the risk of uterine rupture • Longer recovery. • Reduces the risk of pelvic organ prolapse and urinary problems • Option for sterilisation if fertility is no longer desired. Increases likelihood of future vaginal birth. instrumental delivery in up to 39% Future pregnancies – likely to require caesarean delivery, increased risk of placenta praevia / accreta and adhesions with successive caesarean deliveries/ abdominal surgery. Risk of maternal death 4/100 000 Risk of maternal death 13/100 000 Infant outcome Risk of transient respiratory morbidity of 2–3%. Risk of transient respiratory morbidity of 4–5% 0.08% risk of hypoxic ischemic encephalopathy (HIE). < 1 per 10 000 (< 0.01%) risk of delivery-related perinatal death or HIE. 0.04% risk of delivery-related perinatal death. Risks and benefits of opting for VBAC versus ERCS from 39 +0 weeks of gestation

6. Selection of candidates for VBAC One previous prior low-transverse cesarean delivery Clinically adequate pelvis No other uterine scar / previous rupture Physician immediately available throughout active labor, capable of monitoring labor, performing an emergency cesarean delivery Availability of anesthesia & personnel for emergency cesarean delivery ACOG practice bulletin 2010

7. Contraindication to TOLAC Previous uterine rupture Previous high vertical, classical, T shaped cesarean section 3 or more previous cesarean deliveries. Contracted pelvis/CPD Obstetric or Medical complication Malpresentation , APH, Severe PIH, Eclampsia, Placental insufficiency Medical disorders like HTN, Heart disease, Renal disease, Asthma, Seizure disorders Inability to perform emergency cesarean due to insufficient staffing / facilities Where the women herself refuses.

8. Factors influencing success of VBAC Type of prior uterine incision Prior uterine rupture Closure of prior incision Inter delivery interval Number of prior cesarean incisions Prior vaginal delivery Indication for prior cesarean delivery Fetal size Multifetal gestation Maternal obesity

9. Prior uterine rupture Women who have previously sustained a uterine rupture are at increased risk for recurrence during a subsequent attempted VBAC. Counseling regarding the hazards of unattended labor and signs of possible uterine rupture.

10. Closure of prior incision Chapman (1997) and Tucker (1993) --no relationship between a one- and two-layer closure and the risk of subsequent uterine rupture Durnwald and Mercer (2003) --no increased risk of rupture, they reported that uterine dehiscence was more common after single-layer closure Bujold and co-workers (2002) -- single-layer closure was associated with nearly a fourfold increased risk of rupture compared with a double-layer closure

11. Interdelivery interval Having at least 24 months between the date of the last cesarean birth and the due date for this pregnancy increases the chance of successful VBAC and decreases the risk of uterine rupture. Shipp and associates (2001)-- intervals of 18 months or less were associated with a threefold increased risk of symptomatic rupture during a subsequent trial of labor compared with intervals greater than 18 months.

12. Number of prior cesarean incisions Miller and colleagues (1994) -- rupture rates of 0.6% following one cesarean delivery and 1.8% for women with two prior cesarean deliveries. Macones and associates (2005) -- two prior cesarean deliveries—1.8 %—compared with those with one—0.9 %

13. Prior vaginal delivery Previous vaginal birth, particularly previous VBAC , Is The Single Best Predictor For Successful VBAC. 87% to 90% success rate for planned VBAC. The rate of rupture increases with each successive labour , but a prior vaginal delivery also increases the chance of a successful VBAC attempt.

14. Indication for prior cesarean delivery Malpresentation such as breech presentation -91% success rate fetal distress-- the success rate 84 % Prior dystocia is an important predictor of vaginal delivery after prior cesarean. --dystocia as the original indication had a significantly lower success rate compared with those with other indications—54 versus 67 %, respectively.

15. Fetal size No proof that increasing fetal size increases the risk for uterine rupture with VBAC Zelop and associates (2001) compared the outcomes of almost 2750 women undergoing a trial of labor of whom 1.1 percent had a uterine rupture. The rate increased with increasing fetal weight—1.0% for <4 kg, 1.6 % for >4 kg, and 2.4 % for >4.25 kg

16. Multifetal gestation Twin pregnancy – no increase risk of uterine rupture with VBAC Ford and associates (2006) 0.9%, and successful vaginal delivery- 45% Cahill (2005) and Varner (2007) - rupture rates of 0.7 to 1.1% and vaginal delivery rates of 75 to 85%

17. Maternal obesity Obesity decreases the success of VBAC Hibbard and colleagues (2006) -- 85 % with a normal body mass index (BMI), 78% with a BMI between 25 and 30, 70% with a BMI between 30 and 40, and 61% with a BMI of 40 or more.

18. Antenatal care Counseling regarding mode of delivery should ideally start at the time of the sentinel cesarean Women should be offered information regarding the need for the first cesarean and implication it may have for future pregnancies and deliveries. Identify ,at the first antenatal visit all women who have had a previous cesarean section or have a uterine scar, a senior consultant should assess them.

19. Factors to note at booking visit include Number and type of previous uterine scars indications for prior cesarean section any puerperal complications gestation at time of prior cesarean section interconception interval other associated medical problem Anticipated family size History of a successful vaginal delivery and whether this was before or after the uterine scar.

20. Antenatal counseling Women with a prior history of one uncomplicated LSCS , in an otherwise uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of planned VBAC and the alternative on an elective repeat cesarean The antenatal counseling of women with a prior cesarean birth should be documented in the notes A final decision for mode of birth should be agreed between the woman and her obstetrician before the expected/planned delivery date, ideally by 36weeks of gestation.

21. Intrapartum Management Women who have had a previous cesarean section should be offered care during labour in a unit where: There is immediate access to cesarean section. There are on site blood transfusion services or blood can be obtained with in a reasonable amount of time. Facilities for continuous fetal heart monitoring are available, preferably electronic fetal heart monitoring. Specialist obstetricians, anesthetists and pediatrician are available round the clock

22. Continuous fetal monitoring Continuous electronic fetal monitoring is recommended following the onset of uterine contractions for the duration of TOLAC An abnormal CTG is the most consistent finding in uterine rupture and is present in 55% to 87% of these events(guise et al 2004)

23. Partogram for progress of labour A partogram, in addition to monitoring progress of labour , enables effective monitoring of maternal parameters like blood pressure and pulse rate. The duration of labour should be closely monitored with special reference to alert and action line on partogram. Prolongation of labour is an important sign of dystocia.

24. Analgesia Epidural analgesia for labour may be used as part of TOLAC , and adequate pain relief may encourage women to choose TOLAC ( sakala et al 1990, flamm et al 1998) Effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture.

25. Delivery second stage should not exceed 2 hrs. 1 hour to allow passive descent, but no more than 1 hour for active pushing (or 30 minutes if the woman has had a prior vaginal delivery) Assisted delivery, should ideally only be performed by an experienced consultant. This should be in the operating theatre with provision for immediate cesarean section Excessive vaginal bleeding or signs of hypovolemia are potential signs of uterine rupture and should prompt complete evaluation of the genital tract.

26. Role of induction and augmentation of labor in VBAC 2-3 times increased risk of uterine rupture and around 1.5 times increased risk of cesarean section in induced labors compared with spontaneous labor. Lydon -Rochelle and associates (2001) IOL with prostaglandins for VBAC increased the uterine rupture risk more than 15-times compared with elective repeat cesarean delivery.

27. Most Dreaded complication of TOLAC risk of uterine rupture in TOL 0.5% Maternal and or fetal morbidity of rupture 10-25% In rupture, 1.5/10,000 risk of perinatal death & 4.8/10,000 risk of hysterectomy Early diagnosis of uterine scar rupture followed by expeditious laparotomy and resuscitations essential to reduce associated morbidity and mortality and infants. Uterine rupture

28. Uterine rupture – Complete disruption of all layers of uterus associated with one/more of the following- Hemorrhage requiring surgical exploration Hysterectomy, Injury to the bladder Extrusion of any part of feto -placental unit Cesarean delivery for suspected uterine rupture, fetal distress Uterine dehiscence – Asymptomatic uterine disruption (complete or incomplete) having no effect on mother or neonate Uterine rupture V/S Uterine dehiscence

29. clinical features associated with uterine scar rupture abnormal CTG severe abdominal pain, especially if persisting between contractions acute onset scar tenderness abnormal vaginal bleeding hematuria cessation of previously efficient uterine activity maternal tachycardia, hypotension, fainting or shock loss of station of the presenting part change in abdominal contour and inability to pick up fetal heart rate at the previous site.

30. Planning and conducting ERCS ERCS delivery should be conducted after 39+0 weeks of gestation.

31. conclusion There is a consensus (National Institute for Health and Care Excellence [NICE], Royal College of Obstetricians and Gynaecologists [RCOG], American College of Obstetricians and Gynecologists [ACOG]/ National Institutes of Health [NIH] that planned VBAC is a clinically safe choice for the majority of women with a single previous lower segment caesarean delivery. Such a strategy will at least limit any escalation of the caesarean delivery rate and maternal morbidity associated with multiple caesarean

32. references Prior cesarean delivery In: William's obstetrics, 24th edition RCOG Birth After Previous Caesarean Birth, Green-top Guideline No. 45 October 2015 Vaginal birth After Cesarean Delivery In: The management of labor, 3rd edition, India Universities Press,2011;pp 266-276

33. Thank you