-dr.jason zachariahGovt. medical college,Kottayam

Scar rupture

Adherent placenta

Operative interference

Peripartum hysterectomy

Preterm labour

Retained placenta and

PPH

Scar rupture

•Increased with classical CS scar

(4-8%) than LSCS scar(0.5-2%)

•Classical CS scar - weak

elective CS

•LSCS scar rupture: more likely to

occur in labour.

Therefore,integrity of scar should

be assessed

LSCS Classical scar

Apposition Better apposition Difficult

Healing in puerperium

Better as lower segment is quiescent

Imperfect due to contraction & retraction

of upper segment

Placental implantation

May be over the scar Much more likely

Rupture 0.5-2% 4-8%

Timing of rupture In labour In pregnancy & labour

Dehiscence-separation along the line of the previous scar

Rupture –when the unscarred tissue is also involved in separation

1. Elective caesarean section

2. VBAC trial of labour (trial of scar)

LSCS scar Hospitalization at 38 weeks

Classical CS at34 weeks due to possibility

of rupture of scar in pregnancy

If VBAC is contraindicated/ if patient refuses

Timing

• if fetal maturity is sure 39wks• if not spontaneous labour awaited• prev classical CS 38 wks

Adhesions causing difficulty

Injury to bowel / bladder

PPH due to placenta praevia/adherent

placenta

In prev CS + ant placenta chance of

adherent placenta more

Caesarean hysterectomy

Proper case selection :- 2/3 of previous CS TOL;

2/3 of TOL VBAC

Successful trial results in vaginal delivery of a live

fetus without scar rupture

A failed trial is said to occur when a emergency

caesarean section is required or there is scar

rupture

To assess integrity of scar if myometrial

thickness > 3.5mm, decreased risk of rupture

Helps to assess placental location

If placenta implanted over the scar high chance

of adherent placenta on USG no subplacental

sonolucent zone

Previous classical incision

Previous two LSCS

Pelvis contracted or suspected CPD

Previous inverted T/extension of incision

Malpresentations

Suspicion of CPD

Medical /obstetric complication

Multiple pregnancy

Patient’s refusal to undergo trial

Previous history

1. Type of prior uterine incision LS transverse

incision

2. Prior indication if recurrent, elective CS

should be done (success more when prior indication is

breech/fetal distress/placenta previa/ abruption)

3. Prior vaginal delivery (if woman had H/O

vaginal delivery chance of VBAC increased)

4. Post-op infection can make scar weak

How many years back was the CS

done ??

Min 18months to heal the scar, so a gap of

18-24 months is necessary

1) No medical / obstetric complication

2) Average sized baby

3) Vertex presentation

4) No CPD

1) Institutional delivery

2) Continuous CTG monitoring in labour

3) Facilities for performing an emergency CS

Monitoring

• Well equipped hospital with all facilities for

emergency CS

• Spontaneous onset of labour awaited

• IV line

• Cross matched blood should be kept ready

• BP, pulse every 30 min; active phase 15 min

• Continuous heart rate monitoring by CTG

• Partogram progress of labour

• Induction of labour undertaken with

caution

• PGE1 absolutely C/I 2-5x increased

chance of rupture

• Oxytocin is better avoided; if used must

be judiciously

• Epidural analgesia safe

1. Unsatisfactory progress of labour

2. Signs of scar dehiscence

There should be facilities to do an emergency CS within 30 min of taking decision

Late deceleration on CTG 1st sign

Meconium staining of amniotic fluid

Persistent maternal tachycardia

Suprapubic discomfort/scar tenderness

Vaginal bleeding

Blood stained urine

Cut short the second stage with outlet forceps/vacuum

Look for excessive bleeding in third stage-sign of scar rupture

If bleeding is excessive- emergency laparotomy

Observe for 4-6hrs in labour ward

With proper case selection abt 2/3 of prior CS

patients are eligible for trial ;of these 2/3 will

have successful VBAC

Scar rupture 0.5-2 %

Maternal & perinatal mortality are not

increased in VBAC

1. Unsuccessful trial (20-50%) requiring CS

2. Uterine scar dehiscence & rupture

3. Maternal morbidity may be increased for the

groups with unsuccessful TOL

4. Maternal mortality same as in repeat CS

5. Perinatal mortality & morbidity high when

there is scar rupture

STERILISATION

•Increasing risk after each operation

•During third time CS strerilisation

should be considered unless there is

sufficiently strong reason to withhold it