Post LSCS Pregnancy Management protocols

1. Post LSCS PregnancyManagement protocols

2. 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

3. 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

4. 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%

5. Maternal Consequences of PRCD • Anesthesia risks – high spinal, Mendelson’s 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

6. 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)

7. Neonatal Risks of PRCD • Neonatal respiratory morbidity • ↑ admission to NICU (7% vs 4.6% for attempted VBAC)* * ‘Healthy cohort selection bias’

8. Neonatal / Fetal advantages of PRCD • ↓ incidence of neonatal trauma, intra-cranial haemorrhage & Hypoxic ischaemic encephalopathy (vs attempted VBAC) • ↓ incidence of unexplained antepartum stillbirth

9. 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

10. Long Term Maternal Consequences of VBAC • Urinary incontinence (prevalence 21% vs 15.9% for PRCD) • Uterovaginal prolapse

11. 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%)

12. Risks of Failed VBAC • Intra-operative injury during emergency LSCS (1.3% vs 0.6% for PRCD) • Non significant trend towards increased maternal mortality

13. 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

14. 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 < 18 months) • Use of prostaglandins (RR 4.7)

15. Influence of Patient intentions • Patient willingness to undergo VBAC (Informed consent) • Future reproductive intentions

16. 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 < 30 minutes for performing emergency surgery

17. Management During Attempted VBAC • Absolute risk of uterine rupture – 1:100 to 1:200 • 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

18. CHECK LIST FOR SELECTING VBAC

19. 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

20. 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

21. 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

22. Patients intention • Informed consent

23. Thank you