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GYNAECOLOGY UPDATE CME on Aug Powered By Docstoc
					Post LSCS Pregnancy
               Plan of Discussion

   Comparison of Trial of labour vs Planned Repeat

   Selection of patients for VBAC

   Management of patients undergoing VBAC

   Check list for patients planned for Trial of labour
                   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%
    Maternal consequences of PRCD

 ↑ risk of short term maternal morbidity
 Placental abruption in future pregnancies
 Placenta praevia in future pregnancies
 Morbid adhesions of placenta in future
    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)
             Neonatal risks of PRCD

 Neonatal respiratory morbidity
 ↑ admission to NICU (7% vs 4.6% for
  attempted VBAC)*
    * ‘Healthy cohort selection bias’
    Neonatal / Fetal advantages of PRCD

 ↓ incidence of neonatal trauma, intra-cranial
  haemorrhage & Hypoxic ischaemic
  encephalopathy (vs attempted VBAC)
 ↓ incidence of unexplained antepartum
         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
    Long term maternal consequences of
   Urinary incontinence (prevalence 21% vs
    15.9% for PRCD)
    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%)
         Risks of failed VBAC

 Intra-operative injury during emergency
  LSCS (1.3% vs 0.6% for PRCD)
 Non significant trend towards increased
  maternal mortality
         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
            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)
        Influence of Patient intentions

   Patient willingness to undergo VBAC
    (Informed consent)

   Future reproductive intentions
    Prerequisites to attempting VBAC
   Obstetrician available continuously to monitor
   Availability of emergency anaesthesia, neonatal
    and blood banking services
   Availability of continuous electronic fetal
   Institutional capability of decision to incision
    interval of < 30 minutes for performing
    emergency surgery
    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
   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
    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
   Institutional policy on induction of labor in a scarred
   Lack of capability to provide continuous supervision
    during trial of labour
   Lack of institutional capability to undertake expeditious
    operative delivery
    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
    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
    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
             Patients intention

   Informed consent
Thank you

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