2. • Once a cesarean, always a cesarean.
• Cragin, 1916
• Once a cesarean, always a trial of labor?
• Pauerstein, 1966
• Once a cesarean, always a controversy.
• Flamm, 1997
3. • Elective repeat cesarean Delivery
(ERCD) – Also called ERCS (Elective
Repeat Cesarean Section)
• Trial of labor after cesarean (TOLAC)
This can have 2 outcomes
Successful TOLAC – Vaginal Birth
After Cesarean Delivery
Failed TOLAC - Emergency cesarean
OPTIONS FOR A PATIENT
WITH PREVIOUS CESAREAN
4. WHICH WOMEN ARE BEST SUITED TO HAVE
A PLANNED VBAC?
• Planned VBAC is appropriate for and may be offered to the majority of
women with a singleton pregnancy of cephalic presentation at 37+0
weeks or beyond who have had a single previous lower segment
caesarean delivery, with or without a history of previous vaginal birth.
RCOG October 2015
5. Planned VBAC ERCS
72–75% chance of successful VBAC Able to plan a known delivery date in select patients.
~ 0.5% risk of uterine scar rupture • avoids the risk of uterine rupture
• Longer recovery.
• Reduces the risk of pelvic organ prolapse and urinary problems
• Option for sterilisation if fertility is no longer desired.
Increases likelihood of future vaginal
birth. instrumental delivery in up to 39%
Future pregnancies – likely to require caesarean delivery,
increased risk of placenta praevia/accreta and adhesions with
successive caesarean deliveries/ abdominal surgery.
Risk of maternal death 4/100 000 Risk of maternal death 13/100 000
Infant outcome Risk of transient respiratory morbidity of
Risk of transient respiratory morbidity of 4–5%
0.08% risk of hypoxic ischemic
< 1 per 10 000 (< 0.01%) risk of delivery-related perinatal death
0.04% risk of delivery-related perinatal
RISKS AND BENEFITS OF OPTING FOR VBAC
VERSUS ERCS FROM 39+ 0 WEEKS OF GESTATION
6. SELECTION OF CANDIDATES FOR VBAC
• One previous prior low-transverse cesarean delivery
• Clinically adequate pelvis
• No other uterine scar / previous rupture
• Physician immediately available throughout active labor, capable
of monitoring labor, performing an emergency cesarean delivery
• Availability of anesthesia & personnel for emergency cesarean
ACOG practice bulletin 2010
7. CONTRAINDICATION TO TOLAC
• Previous uterine rupture
• Previous high vertical, classical, T shaped cesarean section
• 3 or more previous cesarean deliveries.
• Contracted pelvis/CPD
• Obstetric or Medical complication
• Malpresentation, APH, Severe PIH, Eclampsia, Placental insufficiency
• Medical disorders like HTN, Heart disease, Renal disease, Asthma, Seizure
• Inability to perform emergency cesarean due to insufficient staffing / facilities
• Where the women herself refuses.
8. FACTORS INFLUENCING SUCCESS OF
• Type of prior uterine incision
• Prior uterine rupture
• Closure of prior incision
• Inter delivery interval
• Number of prior cesarean
• Prior vaginal delivery
• Indication for prior cesarean
• Fetal size
• Multifetal gestation
• Maternal obesity
10. CLOSURE OF PRIOR INCISION
• Chapman (1997) and Tucker (1993) --no relationship between a
one- and two-layer closure and the risk of subsequent uterine
• Durnwald and Mercer (2003) --no increased risk of rupture, they
reported that uterine dehiscence was more common after single-
• Bujold and co-workers (2002) -- single-layer closure was
associated with nearly a fourfold increased risk of rupture
compared with a double-layer closure
11. INTERDELIVERY INTERVAL
• Having at least 24 months between the date of the last cesarean
birth and the due date for this pregnancy increases the chance of
successful VBAC and decreases the risk of uterine rupture.
• Shipp and associates (2001)-- intervals of 18 months or less were
associated with a threefold increased risk of symptomatic rupture
during a subsequent trial of labor compared with intervals greater
than 18 months.
12. NUMBER OF PRIOR CESAREAN
• Miller and colleagues (1994) -- rupture rates of 0.6% following
one cesarean delivery and 1.8% for women with two prior
• Macones and associates (2005) -- two prior cesarean
deliveries—1.8 %—compared with those with one—0.9 %
13. PRIOR VAGINAL DELIVERY
• Previous vaginal birth, particularly previous VBAC , Is The Single
Best Predictor For Successful VBAC.
• 87% to 90% success rate for planned VBAC.
• The rate of rupture increases with each successive labour , but a
prior vaginal delivery also increases the chance of a successful
14. INDICATION FOR PRIOR CESAREAN
• Malpresentation such as breech presentation -91% success rate
• fetal distress-- the success rate 84 %
• Prior dystocia is an important predictor of vaginal delivery after
• --dystocia as the original indication had a significantly lower
success rate compared with those with other indications—54
versus 67 %, respectively.
15. FETAL SIZE
• No proof that increasing fetal size increases the risk for uterine
rupture with VBAC
• Zelop and associates (2001) compared the outcomes of almost
2750 women undergoing a trial of labor of whom 1.1 percent
had a uterine rupture. The rate increased with increasing fetal
weight—1.0% for <4 kg, 1.6 % for >4 kg, and 2.4 % for >4.25
16. MULTIFETAL GESTATION
• Twin pregnancy – no increase risk of uterine rupture with
• Ford and associates (2006) 0.9%, and successful vaginal
• Cahill (2005) and Varner (2007) - rupture rates of 0.7 to
1.1% and vaginal delivery rates of 75 to 85%
17. MATERNAL OBESITY
• Obesity decreases the success of VBAC
• Hibbard and colleagues (2006) -- 85 % with a normal body
mass index (BMI), 78% with a BMI between 25 and 30, 70%
with a BMI between 30 and 40, and 61% with a BMI of 40 or
18. ANTENATAL CARE
• Counseling regarding mode of delivery should ideally start at the
time of the sentinel cesarean
• Women should be offered information regarding the need for the
first cesarean and implication it may have for future pregnancies
• Identify ,at the first antenatal visit all women who have had a
previous cesarean section or have a uterine scar, a senior consultant
should assess them.
19. FACTORS TO NOTE AT BOOKING
• Number and type of previous uterine scars
• indications for prior cesarean section
• any puerperal complications
• gestation at time of prior cesarean section
• interconception interval
• other associated medical problem
• Anticipated family size
• History of a successful vaginal delivery and whether this was before or
after the uterine scar.
20. ANTENATAL COUNSELING
• Women with a prior history of one uncomplicated LSCS , in an
otherwise uncomplicated pregnancy at term, with no contraindication
to vaginal birth, should be able to discuss the option of planned VBAC
and the alternative on an elective repeat cesarean
• The antenatal counseling of women with a prior cesarean birth should
be documented in the notes
• A final decision for mode of birth should be agreed between the
woman and her obstetrician before the expected/planned delivery date,
ideally by 36weeks of gestation.
21. INTRAPARTUM MANAGEMENT
• Women who have had a previous cesarean section should
be offered care during labour in a unit where:
• There is immediate access to cesarean section.
• There are on site blood transfusion services or blood can be
obtained with in a reasonable amount of time.
• Facilities for continuous fetal heart monitoring are available,
preferably electronic fetal heart monitoring.
• Specialist obstetricians, anesthetists and pediatrician are
available round the clock
22. CONTINUOUS FETAL MONITORING
• Continuous electronic fetal monitoring is recommended
following the onset of uterine contractions for the duration of
• An abnormal CTG is the most consistent finding in uterine
rupture and is present in 55% to 87% of these events(guise et al
23. PARTOGRAM FOR PROGRESS OF
• A partogram, in addition to monitoring progress of labour ,
enables effective monitoring of maternal parameters like blood
pressure and pulse rate.
• The duration of labour should be closely monitored with special
reference to alert and action line on partogram. Prolongation of
labour is an important sign of dystocia.
• Epidural analgesia for labour may be used as part of TOLAC ,
and adequate pain relief may encourage women to choose
TOLAC (sakala et al 1990, flamm et al 1998)
• Effective regional analgesia should not be expected to mask
signs and symptoms of uterine rupture.
• second stage should not exceed 2 hrs. 1 hour to allow passive
descent, but no more than 1 hour for active pushing (or 30
minutes if the woman has had a prior vaginal delivery)
• Assisted delivery, should ideally only be performed by an
experienced consultant. This should be in the operating theatre
with provision for immediate cesarean section
• Excessive vaginal bleeding or signs of hypovolemia are
potential signs of uterine rupture and should prompt complete
evaluation of the genital tract.
26. ROLE OF INDUCTION AND
AUGMENTATION OF LABOR IN VBAC
• 2-3 times increased risk of uterine rupture and around 1.5 times
increased risk of cesarean section in induced labors compared
with spontaneous labor.
• Lydon-Rochelle and associates (2001) IOL with prostaglandins
for VBAC increased the uterine rupture risk more than 15-times
compared with elective repeat cesarean delivery.
27. • Most Dreaded complication of TOLAC
• risk of uterine rupture in TOL 0.5%
• Maternal and or fetal morbidity of rupture 10-25%
• In rupture, 1.5/10,000 risk of perinatal death & 4.8/10,000 risk of hysterectomy
• Early diagnosis of uterine scar rupture followed by expeditious laparotomy and
resuscitations essential to reduce associated morbidity and mortality and infants.
28. • Uterine rupture – Complete disruption of all layers of uterus
associated with one/more of the following-
Hemorrhage requiring surgical exploration
Hysterectomy, Injury to the bladder
Extrusion of any part of feto-placental unit
Cesarean delivery for suspected uterine rupture, fetal distress
• Uterine dehiscence – Asymptomatic uterine disruption (complete or
incomplete) having no effect on mother or neonate
V/S UTERINE DEHISCENCE
29. CLINICAL FEATURES ASSOCIATED WITH
UTERINE SCAR RUPTURE
• abnormal CTG
• severe abdominal pain, especially if persisting between contractions
• acute onset scar tenderness
• abnormal vaginal bleeding
• cessation of previously efficient uterine activity
• maternal tachycardia, hypotension, fainting or shock
• loss of station of the presenting part
• change in abdominal contour and inability to pick up fetal heart rate at the previous site.
• There is a consensus (National Institute for Health and Care Excellence [NICE],
Royal College of Obstetricians and Gynaecologists [RCOG], American College of
Obstetricians and Gynecologists [ACOG]/ National Institutes of Health [NIH]
• that planned VBAC is a clinically safe choice for the majority of women with a
single previous lower segment caesarean delivery.
• Such a strategy will at least limit any escalation of the caesarean delivery rate and
maternal morbidity associated with multiple caesarean
• Prior cesarean delivery In: William's obstetrics, 24th edition
• RCOG Birth After Previous Caesarean Birth, Green-top
Guideline No. 45 October 2015
• Vaginal birth After Cesarean Delivery In: The management of
labor, 3rd edition, India Universities Press,2011;pp 266-276
Because of vertical hysterotomy, classical incision- inherent danger of uterine rupture hence 1916
After the introduction of Kerr incision in 1921– trial of labor was in option
But as many patients with previous cesarean went into trial of labor, more incidence of uterine rupture were noticed, hence a controversy
ACOG 1999, VBAC should be provided to selected patients gave criterias
However, a review of the previous caesarean delivery records and current pregnancy is recommended to identify contraindications to VBAC.
0.2- 1.5 % risk Induced – 1.02% Augmented –0.87% Spontaneous –0.36%
sIf successful, shorter hospital stay and recovery.
This may however change based on circumstances surrounding maternal and fetal wellbeing in the antenatal period
Risk of anal sphincter injury in women undergoing VBAC is 5% and birthweight is the strongest predictor of this.
6% risk if delivery performed at 38 instead of 39 weeks).
0.1%) prospective risk of antepartum stillbirth beyond 39+0 weeks while awaiting spontaneous labour (similar to nulliparous women).
--(200-900/10000) risk of uterine rupture
VBAC score - admission Bishop score, age, previous caesarean delivery indication, body mass index (BMI) and previous vaginal birth.
a VBAC score of more than 16 was greater than 85%, in contrast to those with a VBAC score of 10 who had a 49% success
Women with prior uterine rupture or classical or T-shaped incision ideally should undergo repeat cesarean delivery when fetal pulmonary maturity is assured, and preferably prior to the onset of labour.
examined the relationship between interdelivery interval and uterine rupture in 2409 women who had one prior cesarean delivery. Uterine rupture developed in 29 women—1.4 percent. Interdelivery
Miller and colleagues (1994) studied 12,707 such women undergoing a trial of labor
The success rate for a trial of labor depends to some extent on the indication for the previous cesarean delivery.
In a large series reported by Wing and Paul (1999), 91 percent of women whose first cesarean delivery was for breech presentation subsequently delivered vaginally.
If fetal distress was the original indication, the success rate was 84 percent.
Ford and associates (2006) analyzed the outcomes of 1850 such women with a prior cesarean delivery who attempted a trial of labor. The uterine rupture rate was 0.9 percent, and the rate of successful vaginal delivery was 45 percent.
Anticipated family size this is important as the longer term risks related to further repeat cesarean section scars med be taken into consideration ( placenta previa, placenta accreta, blood loss , transfusion, hysterectomy and mortality)
The rupture rate rises with each successive labour but a prior vaginal delivery also increases the chance of a successful VBAC attempt.
. A patient information leaflet should be provide with the consultation
Continuous electronic fetal monitoring is recommended following the onset of uterine contractions for the duration of TOLAC
An abnormal CTG is the most consistent finding in uterine rupture and is present in 55% to 87% of these events(guise et al 2004
intravenous access with full blood count and blood group and save
continuous electronic fetal monitoring
regular monitoring of maternal symptoms and signs
regular (no less than 4-hourly) assessment of their cervicometric progress in labour
particularly because the most common sign of rupture is FHR tracing abnormalities.
performed a retrospective population-based study
ACOG 2012- misoprostal is contraindicated, rather amniotomy
Dinoprostal- 1.3% rupture rate miso- 5.6 %
CTG is the most consistent finding in uterine rupture, is present in 66–76% of these events. However, ½ cases present with abnormal CTG and abdominal pain. variable or late decelerations or early decelerations, Deceleration of fetal heart rate to 60 to 70 beats per minute or less that lasts for more than a few minutes that does not return to baseline requires rapid intervention.
Most uterine ruptures> 90% occur during labour (the peak incidence being at 4–5 cm), 18% in 2nd stage, 8% being identified post vaginal delivery
Early diagnosis of uterine scar dehiscence or rupture followed by expeditious laparotomy and neonatal resuscitation are essential to reduce associated morbidity and mortality.
classic triad of a complete uterine rupture (pain, vaginal bleeding, fetal heart rate abnormalities) may present in less than 10% of cases