VAGINAL BIRTH AFTER CAESARIAN SECTION !!

VBAC

1. PRESENTED BY DR. MINARA PARVEEN REGISTRAR DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY UTTARA ADHUNIK MEDICAL COLLEGE AND HOSPITAL VAGINAL BIRTH AFTER CAESARIAN SECTION (VBAC)

2. 20XX Pitch Deck 2 The rate of Caesarian Section has almost tripled in Bangladesh in the past decade, with the most recent one at 45%. Promoting trial of labour after Caesarian section (TOLAC) among appropriate candidates safely decreases the nationwide Caesarian Section rates –in addition to preventing surgical complications and future pregnancy complications associated with Caesarian Section.

3. 20XX Pitch Deck 3 The American College of Obstetricians and Gynaecologists (ACOG) recommends that most women with one previous Caesarian delivery with a low transverse incision be considered as ideal candidates for TOLAC .

4. OPTIONS FOR A PATIENT WITH PREVIOUS CAESARIAN SECTION 20XX Pitch Deck 4 This can have 2 possible outcomes: Successful trial of labour after Caesarian : Vaginal birth after Caesarian delivery (VBAC) Failed trial of labour after Caesarian : Emergency Caesarian Delivery ELECTIVE REPEAT CAESARIAN DELIVERY (ERCD) TRIAL OF LABOUR AFTER CAESARIAN ( TOLAC)

5. WHAT IS THE CURRENT SCENARIO? Pitch Deck 5

6. 20XX Pitch Deck 6 WHY IS THE RATE OF CAESARAIAN SECTION SO HIGH ?

7. WHAT IS VBAC? Vaginal Birth After Caesarean section or VBAC refers to vaginal delivery of a baby with a history of previous Caesarian section.

8. SELECTION CRITERIA OF CASES FOR TRIAL OF LABOUR AFTER CAESARIAN 20XX Pitch Deck 8 ONE PREVIOUS LOWER S EGMENT TRANSVERSE SCAR NONRECURRING INDICATION FOR PRIOR CAESARIAN SECTION Fetal distress Dystocia Antepartum Haemorrhage Malpresentation Failed induction Hypertensive disorders Uncontrolled Gestational Diabetes Mellitus PELVIS ADEQUATE FOR THE FETUS FETAL BIRTH WEIGHT Higher the fetal birth weight, lower is the success rate WOMAN HAVING PRIOR VAGINAL DELIVERY

9. 20XX Pitch Deck INTERPREGNANCY INTERVAL AT LEAST 2 YEARS SPONTANEOUS ONSET OF LABOUR IN PRESENT PREGNANCY (HIGHER SUCCESS RATE) WOMEN WHO ARE ELDERLY OR OBESE HAVE LOWER SUCCESS CONTINUED LABOUR MONITORING POSSIBLE AVAILABILITY OF RESOURCES FOR EMERGENCY CAESARIAN DELIVERY WITHIN 30 MINS OF DECISION SELECTION CRITERIA OF CASES FOR TRIAL OF LABOUR AFTER CAESARIAN

10. TO EXCLUDE THE CONTRAINDICATIONS: Absolute contraindications to VBAC:- History of two or more LSCS Prior classical or T-shaped uterine incision Contracted pelvis or suspected CPD History of prior uterine rupture

11. 11 Relative contraindications to VBAC Unknown uterine scar Low-Vertical uterine incision Malpresentation Multiple pregnancy Post term pregnancy Suspected macrosomia TO EXCLUDE THE CONTRAINDICATIONS

12. 12 PREREQUISITES OF A SUCESSFUL VBAC: 1 previous LSCS only Informed consent POWER: Spontaneous onset of labour PASSAGE: Adequate Pelvis PASSENGER: Longitudinal lie with cephalic presentation No pre-existing medical illnesses complicating pregnancy Availability of blood and blood products Expert obstetrics team with multidisciplinary access ( Anaesthetist and neonatologist)

13. MANAGEMENT PROTOCOL AIM: Promotion of vaginal delivery Prevention of unwanted complication Regular antenatal checkup for the patient should be mandatory. At each visit, enquiry is to be made about the pain or tenderness over the scar or any vaginal bleeding.

14. WHEN TO ADMIT THE PATIENT 14 S pontaneous onset of labor pain On E.D.D. (If no Labor pain starts) Any symptoms suggestive of scar tenderness Any associated obstetric complications and medical disorders

15. 15 COUNSELLING Both the patient and her legal guardians to be counselled about complications and consequences. REASSURANCE MULTIDISCIPLINARY APPROACH There should be a team approach consisting of Senior obstetrician Senior anaesthetist Neonatologist

16. 20XX Pitch Deck 16 INFORMED WRITTEN CONSENT

17. FACILITIES TOLAC should be conducted in a tertiary care center where the following facilities are available NICU Emergency C/S facilities Blood transfusion services Continuous fetal monitoring

18. OBSTETRICAL MANAGEMENT Spontaneous onset of labour is desired Induction of labour : 1. Two to three times increased risk of rupture in induced labour compared to spontaneous labor. 2.Induction with prostaglandin for VBAC increased the risk of rupture 16 fold so we avoid it. 3. Preferable method: 1. Stripping of the membrane 2. Intracervical catheter 3. Oxytocin may be used in selective cases An intravenous line is commenced with Ringer’s solution. Blood sample is sent for Haemoglobin estimation and Blood Grouping and Cross Matching with donors kept standby for any prompt transfusion.

19. LABOUR MONITORING Labour monitoring by PARTOGRAPH CONTINUOUS ELECTRONIC FETAL MONITORING

20. PARTOGRAPH FOR PROGRESS OF LABOUR 20 Fetal well being monitored by Fetal Heart Rate Character of liquor Signs of moulding Progress of labour monitored by Cervical dilatation Cervical effcaement Number of Uterine contractions in 10 minutes Maternal well being monitored by Blood pressure Pulse Temperature Urine output

21. SUGGESTIVE FEATURES OF SCAR RUPTURE MATERNAL FEATURES: Severe abdominal pain persisting between contractions especially over previous scar Acute onset scar tenderness Abnormal vaginal bleeding Hematuria Maternal tachycardia , hypotension or shock Loss of station of presenting part Change in abdominal contour

22. SUGGESTIVE FEATURES OF SCAR RUPTURE FETAL FEATURES:: Any presence of non assuring pattern Any severe variable deceleration Any prolonged deceleration Bradycardia All the above features are warning signs of uterine rupture.

23. ANALGESIA 23 Epidural analgesia may be used for labour and adequate pain relief may encourage women to choose trial of labour after Caesarian. Effective regional analgesia should not mask signs and symptoms of uterine rupture.

24. DELIVERY 24 The second stage should not exceed 2 hours. Prophylactic forceps or ventouse may be used to cut short the second stage ideally in an operation theater by an experienced obstetrician. ActIve management of third stage of labor Fourth stage to monitor maternal well being

25. ADVANTAGES OF VBAC Success rate of VBAC is 72 to 75% Shorter maternal hospital stay Fewer episodes of hemodynamic instability due to blood loss Less need of blood transfusions Elimination of per-operative complications such as trauma to bladder or ureter

26. ADVANTAGES OF VBAC Decreases chances of hysterectomy No anaesthetic hazards Fewer incidence of post operative infections Few thromboembolic events compared to operation Decreased risk of abnormal placentation and need for successive caesarian delivery in next pregnancy Low risk of placenta accreta spectrum disorder Avoidance of future adhesions Breastfeeding established sooner

27. 20XX Pitch Deck MATERNAL: Uterine wound dehiscence Uterine rupture Increased incidence of hemorrhage Increased blood transfusion Increased risks of hysterectomy in case of irreparable damage due to rupture of uterus Increased maternal morbidity POTENTIAL RISKS OF FAILED TRIAL OF LABOR AFTER CAESARIAN (TOLAC)

28. Pitch Deck 28 PERINATAL Perinatal Asphyxia Hypoxic Ischaemic Encephalopathy NICU admission Neonatal death and Stillbirth

29. COMPARISON BETWEEN DIFFERENT TYPES OF INCISIONS

30. UTERINE RUPTURE AND DEHISCENCE 20XX Pitch Deck 30 UTERINE RUPTURE: Complete disruption of all layers of uterus associated with one or more of the following: Haemorrhage requiring surgical exploration Hysterectomy/ Injury to the bladder Extrusion of any part of feto -placental unit UTERINE DEHISCENCE: Asymptomatic separation or thinning of the scar without involving the peritoneal coat and without any hemorrhage.

31. Patient-centered care requires shared decision making, which is a unique process in the context of choosing the mode of delivery . The decision influences not only the mother, but also the baby, whose well-being depends on A mother’s good decision-making. DR.Edwin Cragin , the legendary gynaecologist had famously coined out the phrase Once a ceasarian , always a ceasaran - But the advent of vbac has revolutionised the fiELD of obstetrics and hence the way we think About childbIrth in today’s day and age. VBAC has thus gained renewed trust in ensuring patient satisfaction and lowering maternal and perinatal morbidity and mortality due to operative interference. 31 TAKE HOME MESSAGE

32. THANK YOU