Past section

Thursday, April 19, 2018 2:04 PM

History
• Presenting complaint
• History of presenting complaint
○ Ask about the current pregnancy- LMP, EDD
 T1 – hyperemesis [IUGR lead to LSCS]
 T2 – GDM, PIH [macrosomic baby, IUGR]
 T3 – growth scan large baby /small/normal size, USS finding of placental location after
34 Weeks, abnormality of location, multiple pregnancy [risk of rupture], abnormal
presentation, History of
 vaginal bleeding
○ VBAC counselling - 36 weeks

• Past obstetric Hx
○ Previous section
 When and Where
 Indication – Fetal/Maternal
 Recrrent or non recurrent
 Elective/emergency & how long was she in labour (To find-out the stage of labour)
 Scar - location and type
 Type of CS
 Number of previous CS
 Gestation (preterm labour likely upper segment)
 Type of anaesthesia
 Birth weight
 NVD following LSCS [less likely to rupture]
 Perineal tears
 Post-partum hemorrhage
 Infected scar
 Endometritis following LSCS [severe abdominal pain, high fever, purulent vaginal
discharge, vaginal bleeding, given IV antibiotics]
 Hx of uterine supture
○ Previous miscarriage with surgical management

• Gynaecological History
○ Myomectomy
○ Hysterotomy done [opened endometrium]
○ Hx of subfertility
○ Previous pelvimetry
○ Surgery for incontinence repair

• Past medical history

○ IHD, anemia & other comorbidities

• Family History - DM, HT

• Social History - Social issues, Adequate income, Family support, Future fertility wishes, Need LRT,
Distance from home, Transport facilities,

Examination
• Abdominal examination
o Type of scar, tenderness over scar
 o SFH for IUGR or macrosomia
o Abnormal lie/presentation
o Multiple pregnancies
o EFW

Discussion
 In your patient who has a previous uterine scar, how would you manage?
o I would go for a Trial Of Labor (TOL). This is considered in the absence of contraindications,
in women who present for prenatal care with a history of previous uterine scar
 What are the contraindications to vaginal birth?
o Absolute contraindications
 Previous classical or inverted ‘T’ uterine scar
 Previous hysterotomy or myomectomy entering the uterine cavity
 presence of 2 or more uterine scars
 Previous uterine rupture.
 The presence of a contraindication to labour such as placenta previa
 Malpresentation
o Relative contraindications
 Previous surgery for stress urinary incontinence
 Previous 3rd-4th degree perineal tears
 What are the problems of TOL?
o Uterine rupture
o Maternal morbidity
o Perinatal mortality and mortality morbidity
 What is the success rate of trial of labor after C-section?
o It ranges between 50%-85%. If there are predictors of successful TOL the rate increase upto
82%
 What are the predictors of a successful TOL?
o History of previous vaginal delivery
 The risk after
 0 - 1.6%
 1 - 0.3%
 2 - 0.2%
 3 - 0.35%
o Non recurring indications for c-section
 Malpresentation
 Gestational hypertension
 What should be done at the booking visit of a patient with a previous uterine scar?
o All clinical records of previous C-section, myomectomy and uterine perforations should be
looked for and recorded in the present clinical records
o At the 1st visit the woman should be seen by the most senior member of the clinic team
o If it’s a non specialist unit, the woman should be referred to a specialist unit at the earliest
opportunity for management or shared care
o USS scan should be performed for
 Accurate dating
 Assessment of placental localization
 Exclusion of abnormal placentation (morbid adherence)
o Patient should be assessed for contraindications for Vaginal birth.
o If there are no contraindications, a women with 1 previous transverse LSCS should be
offered a TOL after a discussion about maternal and fetal risks vs benefits
o If the mother requests a elective c-section, even in the absence of contraindications, her
wishes should be respected
 What are the special considerations about TOL regarding these problems?
o As there is a small risk of uterine perforation, TOL should only be considered in a unit where
a immediate c-section can be performed, so that intrapartum emergencies can be managed
 o If such an emergency occurs, the obstetric, anesthetic and pediatric teams should attend to
such emergency. They should be pre-warned when there is such a patient in labor
 What is the risk of uterine rupture according to type of scar?
o Transverse lower uterine scar - 0.2-1.5%
o Vertical incision 1-1.6%
o Classical or ‘T’ incision 4-9%
 What are the factors that increase the risk of uterine rupture during TOL?
o Medical Induction of labor
o TOL in more than 1 previous uterine scar
o Inter delivery interval <18 months - 3 fold rise of risk
 What is the predictor of uterine rupture?
o There is evidence that USS measurement of lower uterine segment myometrial thickness
measured at 36 to 38 weeks is a predictor of uterine rupture
 <3.5mm - risk is 11.8%
 >3.5mm - risk is minimal
 How do you counsel a patient for TOL?
o I would tell the advantages of this procedure, versus the disadvantages. I would tell her
about the complications that she might have to face following TOL
 Compared to C-section, there is less blood loss, shorter hospital stay and rapid recover
with a successful trial of labor
 In a C-section Scarring of uterus - increased risk of placenta previa and placental
abruption.
 Repeat C-section - increased risk of placenta previa and placenta accreata in
subsequent pregnancies
o Risk of febrile morbidity is less in mothers who undergo a TOL and it’s minimum in patients
who have a successful TOL. But it is increased in those attempting a TOL and ultimately
delivering via C-section

 What are the special intra-partum delivery instructions?

o Patient should be advices to present to hospital early in labor or before labor
o IV access should be established
o blood should be cross matched
o Patient should be kept fasting
o There is no contraindication for epidural, but close of monitoring of the patient is essential
o Patient monitoring should be done by,
 a partogram, and any abnormality should be informed to a senior
 Continuous electronic fetal monitoring is mandatory
 Assessing for clinical signs of scar rupture
 What are the symptoms and signs of scar rupture?
o Increase in fetal baseline HR(earliest signs in impending rupture) —> fetal tachycardia —>
decelerations
o Suprapubic tenderness and/or changing pattern of abdominal pain. Pain which continues
between contractions is a worrying sign
o Maternal tachycardia
o Vaginal bleeding
o Cessation of contractions
o Appearance of haematurea
o Loss of presenting part in VE
 What’s the most important reliable first sign of uterine rupture in this patient?
o Sudden onset abnormal fetal heart tracing
 If there is impending scar rupture what should you do?
○ You should send the patient for an emergency c-section
 If there is features of uterine rupture how would you manage?
○ Inform seniors, anesthetist, hematologist, PHO, ICU
○ Oxygen via facemask
 ○ Start IV drip (Hartmann/ N. saline)
○ Get down the cross matched blood & preserve more
○ If DIC occurs
o Inform & get the consent for hysterectomy
o Rush to the theatre with pre medications
 IV Ranitidine 50 mg
 IV Metoclopramide 10 mg
 Na citrate 30 ml
 Prophylactic antibiotics
○ If the bleeding is severe – hysterectomy
○ Repair the sutured site
○ Debrief the woman & husband

 Is digital exploration of the C-section scar postpartum necessary?

o No, it’s not necessary unless there are features of uterine rupture
 Can oxytocin be used to augment labor in this patient?
o Yes, a randomized controlled trial revealed that there is no increase in the risk of uterine
rupture, maternal morbidity or perinatal morbidity and mortality when oxytocin is used to
augment the spontaneous onset of labor. But careful monitoring is essential
o Use of other agents like prostaglandins, misoprostol is not recommended as there is a
increased risk of uterine rupture
 Can we try TOL in a mother with GDM ?
o Yes. GDM is not a contraindication to a TOL
 If the presentation is a breech, can we go fo a TOL?
o No, research evidence shows that it’s better to go for a c-section as it has better perinatal
and neonatal outcome
 Is the risk of uterine rupture increased in a post term mother undergoing TOL?
o No. There is no increased risk compared to a mother in term

Discussion
 Factors in deciding the mode of delivery in previous history of LSCS
o Strength of scar
o Size of the baby
o Pelvis & maternal factors

Strength of scar
Well formed scar
Less number of scars - <2 scars

Types of scar (Strength more in LSCS than classical) Previous incision > 15
months
Previous evidence of uterine, scar infection
Myomectomy with opening into endometrium
 LSCS

 Horizontal incision over lower segment.

 Commonest
o Easy to perform
o Take the baby out
o Suture the muscle layers
 Less bleeding
 Less infection
Less strength

Upper segment scar

 Mid line scar over upper segment

 Increase bleeding
 Less approximation
 Higher incident of rupture next time if NVD
 Indications
o Fibroids in lower segment
 o Placenta previa
o Preterm breech with poorly formed lower segment
o Transverse lie with ruptured membranes
o Transverse lie with congenital anomaly of uterus Inverted T scar
 Less strength J shape scar
 Indications
o Transverse lie
o Premature baby
o Difficulty in delivering the baby

Size of the baby

o By clinically - examination
o USS

Size of the pelvis & maternal factors

o Clinical pelvimetry
o Maternal comorbidities
 DM
 HT
 Placenta previa
 Increase age

What should you do in emergency cesarean section?

o Informed written consent
o IV cannula
o Take blood for DT & preserve 1 pint
o Pre medications
 IV Ranitidine 50mg
 IV Metoclopramide 10mg
o IV N/S infusion of 1 pint
o Send with prophylactic antibiotics
 IV Metronidazole 500mg
 Ampicillin 2g
o Inform PHO
o Prepare the theatre list & inform theatre, Anesthetist
o Give Na Citrate before induction of anaesthesia
o Inform PBU if the baby is premature

 Absolute contraindications for vaginal birth

o Previous classical/Inverted “T” uterine scar
o Previous hysterectomy or myomectomy entering the uterine cavity
o Previous uterine rupture
o Presence of contraindications to the labour such as placenta previa
o Malpresentations

 Relative Contraindications for vaginal birth

o Previous surgery for stress incontinence
o Previous 3rd or 4th degree perineal tears.