vaginal birth after cesarean section


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Introduction : : 

Introduction : “once cesarean always cesarean” – Cragin,1916 Low transverse uterine incision –by Kerr,1920 1950 onwards,vaginal delivery tried in nonrecurring cause with prior low transverse incision Incidence of uterine rupture -4% vs 0.5% with success rate 30-40% in Prior LSCS

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1980-1988 Cs rate rises ,17% - 24% In 1988 ACOG recommended –most women with one previous LTCS should be counseled to attempt labor in subsequent pregnancy. 1996 VBAC rate ↑dramatically, almost a third women with prior LTCS delivered vaginally. But comparing various risks VBAC rates again decreased gradually & reduced to 10% in 2004 in US

Fetal & Maternal risks with VBAC : 

Fetal & Maternal risks with VBAC

Landon et al. N Engl J Med 2004

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Overall, woman attempting VBAC have 50% greater morbidity, though this depends on background risks of failure. [B] Absolute risk of maternal morbidity- highest with failed VBAC- 14.1% Intermediate with PRCS -3.6% Lowest with successful VBAC -2.4% [B] RCOG 2008

Maternal risks with VBAC Vs PRCD : 

Maternal risks with VBAC Vs PRCD Short term :VBAC Vaginal & perineal laceration Trauma to anal sphincter & mucosa Uterine rupture Serious intraoperative injury during EmLUCS Short term :PRCD Febrile morbidity Blood transfusion Hysterectomy Venous thromboembolism

Long term maternal risks : 

Long term maternal risks VBAC: Urinary incontinence in operative vaginal delivery Rupture in this pregnancy ↑es rupture risk in future pregnancy PRCD : Lower fertility Placental abruption Anterior placenta previa wth morbid adherence Morbidly adherent placenta-accreta, percreta Increased adherence & operative injury in future sx- hysterectomy

Fetal risks : 

Fetal risks Short term: VBAC Uterine rupture with antepartum stillborn HIE & intrapartum still born Intracranial injury Neonatal sepsis PRCD : Respiratory morbidity RDS TTN Primary pulmonary hypertension

Long term fetal risks : 

Long term fetal risks VBAC : HIE leading to cerebral palsy PRCD : Childhood asthma Early onset schizophrenia in later life from complicated cesarean delivery

Candidates for Vaginal Birth after Cesarean Delivery (VBAC) : 

Candidates for Vaginal Birth after Cesarean Delivery (VBAC) Classic candidates One previous prior low-transverse cesarean delivery done for nonrecurring indication Clinically adequate pelvis , without any contraindication of vaginal delivery Having singleton pregnancy in longitudinal lie & cephalic presentation No other uterine scars or previous rupture Physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery Availability of anesthesia and personnel for emergency cesarean delivery ACOG, 2004

Special candidates : 

Special candidates RCOG 2008

Predictive Normogram : 

Predictive Normogram

Predictive normogram : 

Predictive normogram

Predictors of scar rupture Vs successful VBAC : 

Predictors of scar rupture Vs successful VBAC

Type of prior uterine incision and Estimated Risks for Uterine Rupture : 

Type of prior uterine incision and Estimated Risks for Uterine Rupture ACOG, 2004

Closure of prior incision : 

Closure of prior incision Single layer closure of a low transverse incision associated with 4- 5 fold increased risk of scar ruptures after adjustment of other maternal & demographic factors Uterine rupture more likely with previous single layer closure. [B] BUJOLD E, Am J Obstet Gynecol,2002

Timing of previous C.S : 

Timing of previous C.S Performed in latent lobour or without labour Vs in labour Nulliparous labour needs stronger & longer contractions to dilate nulliparous cervix- more strain on old scar- more chance of scar rupture

Interdelivery interval : 

Interdelivery interval MRI studies of myometrial healing suggests complete uterine involution & restoration of anatomy needs at least 6 months. Interpregnancy interval <6 months -3 fold increased risk of uterine rupture, & Interval 6-18months does not significantly alters rupture risk. SHIPP & ASSOCIATES, 2001

No. of prior C.S : 

No. of prior C.S Risk of uterine rupture increases with increase in the no. of prior cesarean section. In one study 0.6% Vs 1.8% incidence of rupture with previous one Vs two L.T.C.S MILLER & ASSOCIATES ,1994

Thickness of lower uterine segment by USG : 

Thickness of lower uterine segment by USG Measurement of lower uterine segment thickness at 3rd trimester may have some predictive role for uterine rupture in VBAC. If lower segment become very thin chances of scar rupture is very high. But absolute criteria needs further evaluation.

History of prior vaginal delivery : 

History of prior vaginal delivery Previous vaginal delivery either before or following cesarean birth significantly improves the prognosis of future trial for VBAC & lowers the risk of uterine rupture. According to ACOG(2004) , VBAC can be considered even in a woman with prior two L.T.C.S only if she has a prior vaginal delivery.

Indication of prior C.S : 

Indication of prior C.S Success rate of vaginal delivery is good when indication of previous C.S was breech presentation or fetal distress. (91% & 84%-PAUL,1999) Success rate low if baby WT in recent pregnancy >500gms than previous one. (34%-PAUL,1999) Significant low success rate of VBAC where prior indication was dystocia.

Fetal size : 

Fetal size Increasing fetal size increases risk of rupture in VBAC shows by various studies- Zelop & associates(2001) shows – rupture rate in VBAC- 1% for FW<4000g, 1.6% for 4000-4250g, & 2.4% with FW>4250g Planned preterm VBAC have similar success rate like planned term VBAC but with a lower risk of scar rupture. [C]

Multifetal gestation : 

Multifetal gestation Twin pregnancy as such does not increase risk of rupture with VBAC, but There may be need for intrauterine manipulation before delivery of 2nd twin , which must be considered according to the situation. Caution must be advised when considering planned VBAC in twin pregnancy [B]

Maternal obesity : 

Maternal obesity Maternal obesity adversely affects success of VBAC Success rate highest with BMI <25 & success rate gradually decreases as BMI increases, & become minimum when >40 (85% Vs 61%, HIBBARD & colleagues, 2006)

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Gestational diabetes : History of gestational diabetes associated with a high background rate of failure & low threshold for emergency C.S during VBAC. [B] Slow progress of labor : Associated with increased failure rate in VBAC. [B]

Informed consent : 

Informed consent Decision of either VBAC or planed repeat cesarean section should be taken By the informed woman, In conjunction with her physician After thoroughly analyzing that particular situation.

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Recommended Counseling Points for Women with a Prior Cesarean Delivery( RCOG,2008)

Recommended Counseling Points for Women with a Prior Cesarean Delivery( RCOG,2008) : 

Recommended Counseling Points for Women with a Prior Cesarean Delivery( RCOG,2008)

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RCOG 2008

Conduction of labor in VBAC : 

Conduction of labor in VBAC Advised to get admitted in hospital early in the labor Once labor established , an I.V drip should be maintained. Blood should be sent for CM & kept reserved for future transfusion. [GPP] Facility should be available for continuous intrapartum monitoring, EmLUCS, advanced neonatal resuscitation. [B] FHR should be monitored carefully, & continuous electronic fetal HR monitoring should be instituted. [B]

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Epidural analgesia can be used safely during labour(ACOG,2007) [C] Spontaneous onset of labor is most desirable If cervix is favorable , amniotomy may be done without any additional risks Continuous monitoring of progress of labour & maternal vitals should be done. [GPP] If progress satisfactory, successful outcome is expected Routine use of I.U pressor catheter for early detection of rupture is not recommended. [C]

Cervical ripening & labor stimulation : 

Cervical ripening & labor stimulation Two to three fold increased risk of uterine rupture & 1.5 fold increased risk of C.S in induced &/ augmented labor than spontaneous labor in VBAC. [B] So oxytocin should be used with extreme caution & only when uterine activity is clearly inadequate & great care should be taken to avoid uterine hyperstimulation. [B]

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Prostaglandins for cervical ripening is associated with increased risk of scar rupture during VBAC Rupture rate clearly higher than spontaneous labor in most of the studies. Thus ACOG(2004), discourages the use of prostaglandin analogues for cervical ripening or labor induction during VBAC. [GPP] (2.9% Vs 0.9% in PGE2 gel Vs spontaneous, RAVASIA ET AL,2000)

Contd.. : 

Contd.. 2nd stage of labor is the period of maximum strain to the lower uterine segment, so… If 2nd stage is prolonged & head is low in the pelvis –this may be shortened with assisted vaginal delivery, by forceps or by vacuum

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3rd stage is usually uneventful. Routine exploration of uterine scar after delivery is no longer recommended, because cases needs surgical repair are almost invariably symptomatic. [B] Woman must be observed intensely in early postpartum period for any signs of scar rupture

Recent trends of VBAC : 

Recent trends of VBAC

Summary : 

Summary “Best answer” for a given woman with a prior C.S is probably unknown. The decision to attempt VBAC is complex, requires careful counseling & should take into consideration : Maternal preferences & priorities plans for future pregnancies Presence of factors that influence likelihood of success Vs scar rupture importance placed on rare but serious adverse outcomes

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The National Institute of health is planning to organize a “consensus development conference” in 2010 to minimize some confusion & to arrive at a decision & to elucidate current knowledge on VBAC .

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