Azadeh Akbari Sene MD 1

Pregnancy and Delivery after a Prior Cesarean

Section

Azadeh Akbari Sene

Assistant Professor in OBGYN/ IVF FellowshipShahid Akbar-abadi IVF CenterIUMS

Azadeh Akbari Sene MD 2

Cragin 1916: once a CS, always a CS Kerr 1920s: Low-transverse incision with 0.5% chance of

uterine rupture Hellman 1971: 30-40% VBAC Merrill 1978: 83% VBAC in Texas university ACOG 1988: most women with one previous low-

transverse CS should be counseled to attempt labor VBAC 1996: One third of prior CS ACOG goal for 2010: VBAC i0f 37% in women at 37

weeks or more with singleton cephalic pregnancy with a prior Kerr incision

Management of a prior CSModern Obstetrical Controversy

Azadeh Akbari Sene MD 3

After 1989: growing number of uterine rupture and adverse prenatal outcome with VBAC

Hamilton 2009: primary CS rate>30% , VBAC rate dropped to 8.5%

Management of a prior CSModern Obstetrical Controversy

Azadeh Akbari Sene MD 4

Higher uterine rupture rate but only 7 in 1000 Higher rates of stillbirth and HIE Absolute rate of uterine rupture resulting in fetal death

or injure = 1 per 1000 (MFMU 2004, Chauban 2003, Mozurkewich 2000, Smith 2002)

Is this risk acceptable?

Associated risks of VBAC versus elective repeated CS

Azadeh Akbari Sene MD 5

Maternal mortality rate does not differ significantly (Landon

2004, Mozurkewich 2000)

Maternal morbidity rate (hysterectomy, uterine rupture, transfusion, infection) is significantly greater (MFMU 2004, Rossi

2008, McMohan 1996)

Increased incidence of overall maternal complications when failed VBAC compared to a successful VBAC (El-

Sayed 2007, Rossi 2008)

Associated risks of VBAC versus elective repeated CS

Azadeh Akbari Sene MD 6

Developing nomograms to help predict a successful trial of labor

Grobman nomogram 2007 (considering Age, BMI, Race, Vaginal delivery since last CS, Previous vaginal delivery, Recurrent primary indication)

Risk of rupture is not predictable with clinical characteristics (Srinivas 2007, Macens 2006, Grobman 2008)

Candidates for VBAC

Azadeh Akbari Sene MD 7

ACOG recommendations for selecting appropriate VBAC candidates:

1. One previous prior low-transverse CS2. Clinically adequate pelvis 3. No other uterine scars or previous rupture 4. Physician immediately available throughout active labor

capable of monitoring labor and performing an emergency CS5. Availability of anesthesia and personnel for emergency CS

Candidates for VBAC

Azadeh Akbari Sene MD 8

Highest risk of rupture with prior vertical incision extending into fundus

The risk of classical scar rupture before the onset of labor or several weeks before term

Type of prior uterine incision

Prior incision Estimated rupture rate (%)

Classical 4-9

T-shaped 4-9

Low-vertical 1-7

Low-transverse 0.2-1.5

Prior lower segment rupture 6

Prior upper uterus rupture 32

Azadeh Akbari Sene MD 9

Prior lower-segment vertical incision without fundal extension may be candidates for VBAC ?? (ACOG 2004)

It is helpful in the operative report to document the exact extent

Prior preterm CS (<34w) higher uterine rupture rate ?? (Sciscione 2008)

Uterine malformation and prior CS: No significant risk (Erez 2007)

One versus two layer closure of incision: insufficient evidence ??

The type or prior incision is the most important factor for considering a trial of labor

Type of prior uterine incision

Azadeh Akbari Sene MD 10

Azadeh Akbari Sene MD 11

Women with

Prior uterine rupture Classical or T-shaped incisions

Should undergo repeat CS when fetal pulmonary maturation is assured

Preferably prior to the onset of laborCounseling for warning signs

Clinical guide

Azadeh Akbari Sene MD 12

Inter-delivery interval: at least 6 months for complete uterine scar healing (18 months?)

Number of prior CS? Prior vaginal delivery: The most favorable prognostic factor Considering VBAC with two previous CS in women with

prior vaginal delivery Indication for prior CS: lower success rate with dystocia Fetal size↑ risk of rupture↑ Preterm fetus risk or rupture ↓ Multifetal gestation : No increased risk Maternal obesity: success rate ↓

Other factors for VBAC success rate

Azadeh Akbari Sene MD 13

Significant adverse neonatal morbidity has been reported with elective CS prior to 39 completed weeks

Labor and delivery considerations

Azadeh Akbari Sene MD 14

Any attempt to stimulate cervical ripening or to induce or augment labor uteirne rupture risk ↑

Oxytocin: infusion dose ↑ uterine rupture risk ↑ Prostaglandins: uterine rupture risk ↑ Sequential prostaglandins and oxytocin more

increased risk EASI ? Laminaria? Stripping? Epidural analgesia: may safely be used Uterine scar exploration: only if significant bleeding is

encountered

Labor concerns and labor stimulation

Azadeh Akbari Sene MD 15

Cochrane matanalysis 2013:

There is insufficient data available from RCTs on which to base clinical decisions regarding the optimal method

of induction of labor in women with a prior cesarean birth

Labor concerns and labor stimulation

Azadeh Akbari Sene MD 16

Wound/ uterine infection Placenta previa Transfusion Hysterectomy Placenta accreta Bowel/bladder injury ICU admission Maternal mortality Cesarean scar pregnancy

Complications with multiple repeat CS

Azadeh Akbari Sene MD 17

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