Trail of labour after cesearean section.

Tolac version vbac

1. WHO guidance is clear that CS is essential for those who need it, recommended rate of 10% to 15% to improve maternal and perinatal outcomes and prevent maternal and neonatal mortality and morbidity.

2. SUCCESS OF TOLAC PREVIOUS 1 LSCS + VAGINAL DELIVERY 85-90% PREVIOUS 1 LSCS 72-75% PREVIOUS 2 LSCS 62-75% PREV LSCS FOR BREECH PREVIOUS LSCS FOR FETAL DISTRESS 84-90% 73-80% BMI<30 78% VBAC SCORE > 16 VBAC SCORE < 10 85% < 50% SCAR THICKNESS > 2.5 MM SCAR THICKNESS 2-2.4 MM SCAR THICKNESS < 2 MM 61% 40% 9% FETAL WEIGHT > 4KG 50% IUD IN CURRENT PREGNANCY 87%

3. PREGNANCY WITH PREVIOUS RUPTURE Site of rupture is lower segment – rate of repeat rupture or dehiscence is 6% If rupture scar is in upper segment – repeat rupture is 32% With previous uterine rupture – Repeat caesarean delivery before onset of labor is recommended. Suggested time of delivery 36-37 weeks.

4. FACTORS INFLUENCING SUCCESS OF VBAC Prior vaginal delivery/ prev successful VBAC: single best predictor for successful VBAC (success of VBAC is 85-90%) -RCOG2015 Type of prior uterine incision: transverse: most important factor when considering a TOLAC (ACOG) Number of previous LSCS:1 better than 2 Indication of LSCS: malpresentation > fetal distress> arrest of dilatation Spontaneous labor Bishop's score: better score more success Scar thickness: smallest measurement between amniotic fluid and maternal urine (at previous scar site). No fixed cutoff. RCOG2015: 2.1-4mm scar has negative predictive value and scar 0.6 2mm has positive predictive value for occurance of uterine defect Jatrow 2016 High risk Intermediate risk Low risk Scar thickness < 2mm 2-2.4 mm >/=2.5 mm TOLAC success 9% 42% 61%

5. 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. Such a strategy will at least limit any escalation of the caesarean delivery rate and maternal morbidity associated with multiple caesarean. Underuse of Cesarean Section Maternal & perinatal mortality and morbidity, yet conversely, Overuse of CS has not shown benefits and can create harm. CONCLUSION

6. TOLAC A planned attempt to delivery vaginally by a woman who has had a pervious caesarean delivery, regardless of the outcome.

7. FETAL OUTCOMES PLANNED VBAC ERCD at 39 weeks RISK OF DELIVERY RELATED PERINATAL DEATH 0.04% <0.01% RISK OF HIE 0.08% <0.01% RESPIRATORY MORBIDITY TRANSIENT TACHYPNEA OF NEWBORN RDS 2-3% 0.05% 4-5% 0.5% Respiratory morbidity in delivery at 37, 38, 39 weeks is 11,6,1.5% respectively

8. CONTRAINDICATION TO TOLAC Previous uterine rupture Previous high vertical, classical, T shaped cesarean section (if T extends to upper segment) 3 or more previous cesarean deliveries. Any contraindication to Vaginal delivery irrespective of scar (such as placenta previa / fetal distress) Inability to perform emergency cesarean due to insufficient staffing / facilities Where the women herself refuses.

9. CONSEQUENCES POST CESAREAN…… Maternal – Less risk of Urinary incontinence & Pelvic Organ Prolapse . Increased risk of postmenstrual spotting (Scar defect) Dysmenorrhea Cesarean scar ectopic Pelvic adhesions – Chronic Pelvic Pain Subfertility Hysterectomy & its complications later in life Future pregnancy adverse events like previa , Placenta accreta spectrum, placental abruption, Uterine rupture, miscarriages and stillbirth.

10. CONSEQUENCES: Neonatal – Altered Immune Development Allergy, atopy & asthma Reduced Intestinal gut, microbiome diversity Risk childhood obesity Moderately elevated risk of severe LRTI in infants born by planned CS as compared to those born vatinally . Moderately elevated risk of severe LRTI in infants born by planned CS as compared to those born vatinally . A large study ( Paixao & Colleagues), 25% increase in child mortality in infants born via CS in low risk mothers. High risk mothers mortality rate was lower among infants born via CS(Clinically indicated CS)

11. C-sections………The Consequences………….in the unborn…………… Children born by C-section also suffer increased rates of diseases, including asthma, type I diabetes, allergies, obesity, as well as reduced overall cognitive functioning and lower academic performance

12. The scary picture: Caesarean deliveries Women who given birth via C-section have an increased risk. Of inclusion scar tearing open during a later pregnancy or labor (uterine rupture), Placenta previa Placenta accreat , placenta increta , and placenta percreta (when the placenta grows deeper into the uterine wal than 0000000 Long-term risk and benefits associated with cesarean delivery for mother, baby, and subsequenty pregnancies: Systematic review and meta analysis.

13. OPTIONS FOR A PATIENT WITH PREVIOUS CESAREAN PREGNANCY WITH PRIOR CESAREAN TRIAL OF LABOUR AFTER CESAREAN ELECTIVE REPEAT CESAREAN DELIVERY VAGINAL BIRTH AFTER CESAREAN 72-76% EMERGENCY CESAREAN

14. RISK OF RUPTURE IS HIGH – Previous classical incision, T shape incision Prior uterine rupture Extensive transfundal uterine surgery.

15. Second Trimester preterm delivery or fetal death previous caesarean Frequency of uterine rupture < 1% Outcomes are similar to those women with unscarred uterus. Tolac should be encouraged after weighing risks and benefits.

16. CLINICAL FEATURES ASSOCIATED WITH UTERINE RUPTURE Abnormal CTG (70%) most common, earliest Severe abdominal pain, especially if persisting between contractions Scar tenderness Maternal tachycardia, Abnormal vaginal bleeding Hematuria Cessation of previously efficient uterine activity 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. asymptomatic in 48%. some may have a clinical picture similar to abruption

17. DELIVERY Tolac to be attempted in facilities- suitably staffed, intrapartum care & monitoring equipped for emergency cesarean delivery & advanced neonatal resuscitation. 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 Epidural is not contraindicated. (be cautious if required dose is high for pain relief) Post delivery scar exploration: not routinely recommended Excessive vaginal bleeding or signs of hypovolemia are potential signs of uterine rupture and should prompt complete evaluation of the genital tract.

18. COUNSELLING FOR TOLAC Potential risks & benefits of TOLAC and ERCD to be discussed and documented A VBAC calculator can be used Obtain patient's previous medical records early in antenatal period. Consider intended family size and the risk of additional caesarean deliveries. Shared decision making Documentation of counselling and the management plan should be included in the medical record .

19. BENEFITS OF TOLAC A successful Vbac – Avoids major abdominal surgery Lower rates of haemorrhage , thromboembolism and infection A shorter recovery period Decrease risks of multiple caesarean deliveries — abnormal placentation previa & accreta , hysterectomy, bowel bladder injury, multiple blood transfusion, infections. VBAC fewer complications than ERCD. But failed TOLAC associated with more complications.

20. Role of induction and augmentation of labor in to 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. sweeping, transcervical foleys , amniotomy : safest low dose PGE2: (gel + oxytocin : 1.4% rupture risk, only gel: no increase in risk) misoprostol is contraindicated decision for IOL to be made by assessment by senior obstetrician Augmentation : dose of oxytocin should be less than 20mIU/min

21. Role of induction and augmentation of labor in to Interdelivery interval: Interdelivery inteval should be > 12mm 3 times increased risk of rupture if less interdelivery inteview Patient height (taller patients better outcome) Age <40 yrs BMI < 30 POG<40 weeks (current pregnancy) Baby weight <4kg < LSCS baby weight IUD in current pregnancy Doctor on duty/sufficient staff / facility at hospital BMI 19-25 25-30 30-40 >40 SUCCESS RATE 85% 78% 70% 60%

22. Among the Indian States, the highest percentage of C-section deliveries was in Telangana – rising from 55.33 per cent in 2020-2021 to 54.09 percent in 2021-2022.

23. The World Health Organization (WHO) recommends the caesarean deliveries not exceed 10to15 per in any nation, the Health Management Information System (HMIS) has reported 20.5 percent of C-section deliveries in 2019-2020, and then to 23.29 percent in 2021-2022. The rising trend…..

24. MATERNAL OUTCOME PLANNED VBAC ERCD 72-75% chance of successful VBAC Able to plan a known delivery date in selected patients UTERINE RUPTURE 0.5% Induced: 0.5 – 1.5% Augmented: 0.9 – 1.9% 0.02% MATERNAL DEATH 4 PER LAC 13 PER LAC RUPTURE PREGNANCIES Increases LIKELIHOOD OF future vaginal birth. Instrumental delivery in 39% Increased chances of repeat LSCS RISK OF (IN FUTURE PLACENTA PREVIA ACCRETA HYSTERECTOMY ADHESIONS BOWEL BLADDER INJURY NOT INCREASED INCREASED SPHINCTER INJURY INSTRUMENTAL DELIVERY INCREASED NOT INCREASED