Vbac

1. Previous LSCS
• Age 27 years
• G2P1L1 with Previous caesarean section
• GA- 40th week of pregnancy
• Admitted at 4:15 pm
• Was diagnosed with oligohydramnios.
• LCB- 2 years via cesarean because of a
breech presentation.
• The type of incision performed was
undocumented.

2. Time MPR CON FHR/MIN EFF (%) DIL (CM) ST INTERVE
NTION
4.15 PM 85 0-1 143 25 1 -2
7.00 PM 92 0-1 147 25 1 -1
11 PM 90 1-2 145 70 3 -1 OXY
1.30 AM 94 2-3 150 80 4 -1 EA
3.30 AM 90 2-5 110 80 4 -1 4miu
5.30 AM 98 Difficult 70/1 100 9 0 LLP/O2/
6miu
6.15AM 96 Difficult 140/2/90 100 10 0
6.45 AM 108 Difficult 110-120/
50-60
7.15 AM 124 Not
traceable
120-
130/80
7.30 AM 127 Not
traceable
120-130 Not sure of MPR &FHR
7.40 AM 128 Not
traceable
126/
50
LSCS

3. • Resuscitated
• Transferred to NICU
• pH-6.87
• Neonatal seizures
• Suffered profound
developmental ,
cognitive & neurological
disability

4. What went wrong
• Type of cesarean section not documented
• Prolonged latent phase
• Delay in intervention
• Lack of knowledge on the part of the resident
doctor.

5. LSCS and TOLACLower
Segment
Caesarean
Section
Trial
of
Labour
After
Caesarean
Section

6. Objectives
• The students should be able to
– Explain various terminology associated with
caesarean section
– Differentiate types of caesarean section
– Enumerate indications of TOLAC
– Counsel to the patient regarding TOLAC

8. Understand the terms…..
• Caesarean section [ LSCS/ CLASSICAL]
• Post caesarean pregnancy
• Primary caesarean section
• ERCS[ Elective repeat caesarean section]
• TOLAC/VBAC
3/30/2016

10. LSCS CLASSICAL
Apposition More perfect Difficult to
appose as thicker
musculature
Healing Part of uterus
remains inert
Part
contracts/retracts
Stretching effect Along the line of
scar
At right angles
Scar rupture 0.2% 4-9%
Mortality less more

11. Predictors of VBAC Success or
Failure
Increased Chance of Success Decreased Chance of Success
Prior vaginal delivery Maternal obesity
Prior VBAC Short maternal stature
Spontaneous labor Macrosomia
Favorable cervix Increased maternal age (>40 y)
Nonrecurring indication (breech
presentation, placenta previa, herpes)
Induction of labor
Preterm delivery
Recurring indication (cephalopelvic
disproportion, failed second stage)
Increased interpregnancy weight gain
Latina or African American race/ethnicity
Gestational age ≥41 wk
Preconceptional or gestational diabetes
mellitus

12. Mode of delivery
• Once a caesarean always a caesarean?
• Classical caesarean/ hysterotomy ERCS
• LSCS ERCS?
TOLAC?
ASSESS SCAR INTEGRITY
3/30/2016

13. Integrity of scar
• Factors to consider:
• Previous operative notes
• Defect in scar in inter-pregnancy interval
• Short inter-pregnancy interval
• Pregnancy complications[ twins/ polyhydramnios]
• Previous vaginal delivery.
Indication of previous CS
Extension of the uterine
incision
Puerperal sepsis
3/30/2016

14. Predictors of Uterine Rupture
Increased Rate of Uterine
Rupture
Decreased Rate of Uterine
Rupture
Classic hysterotomy Spontaneous labor
Two or more cesarean deliveries Prior vaginal delivery
Single-layer closure Longer interpregnancy interval
Induction of labor Preterm delivery
Use of prostaglandins
Short interpregnancy interval
Infection at prior cesarean
delivery

15. Management of post caesarean
pregnancy.
• Manage as high risk
• Elective hospitalisation
 36 wks- classical CS/ hysterotomy
 38wks-LSCS
• Mode of delivery
 Classical CS/ other extensions– ERCS[ 38 wks]
 LSCS– Individualise
----ERCS at 39 wks
---- TOLAC[spontaneous/induction]
3/30/2016

16. References
• DC Dutta textbook of obstetrics, 6th edition.
• http://emedicine.medscape.com/article/2721
87-overview

18. 2010 ACOG guidelines make the
following recommendations[3] :
• On the basis of level A evidence, the 2010 ACOG guidelines make the following
recommendations[3] :
• Most women with a prior cesarean delivery with a low transverse incision are candidates for VBAC
and should be offered TOLAC.
• Epidural anesthesia may be used as part of TOLAC.
• Misoprostol should not be used for patients who have had a prior cesarean delivery or major
uterine surgery.
• On the basis of level B evidence, TOLAC may be considered for the following patients[3] :
• Women with 2 previous low transverse cesarean deliveries
• Women with 1 previous cesarean delivery with a low transverse incision who are otherwise
appropriate candidates for twin vaginal delivery
• Women with 1 previous cesarean delivery of unknown incision type, unless clinical suspicion of a
previous classical uterine incision is high
• Level B evidence was also found for the following:
• Induction of labor during TOLAC is not contraindicated.
• In women with a prior low transverse uterine incision who are at low risk for adverse maternal or
neonatal outcomes from external cephalic version and TOLAC, external cephalic version for breech
presentation is not contraindicated.