Presented by roll no.

45,46,47,48,49
9th semester
Moderator: Dr. JyanDip Nath
Name of the patient: Rita Das
Age: 24years
Religion: Hindu
Hospital No.: 127482/17
Address:
c/o. Amar Das
village: Dolai gaon
P.O. Bongaigaon
P.S. Bongaigaon
District. Bongaigaon
State. Assam

Date of admission : 31st July,2017

Date of examination: 31st July,2017
Socio-economic status:
Her husband has passed HSLC and is a driver
She is class 7th passed and is a housewife
They consume drinking water from tube well which is not filtered
They live in a kuchcha house using sanitary latrine
Their monthly income is around Rs.10000/-
Per capita income is Rs.2000/- per month

Duration of marriage : 5years

Last menstruation period: 19th December,2017

Expected date of delivery: 26th September,2017

Her gravida - 2,pariy - 1,abortion -0,living - 1

Chief Complaints:
1.cessation of menstruation for 8 months
2.Pain abdomen for 12 hours
3. Draining per vagina for 12 hours

History of present illness:

First Trimester:
In the first trimester, the patient complaints of cessation of menstruation. She
gives history of nausea and vomiting. There was no history of bleeding per
vagina, pain abdomen , fatigue, fever or rash. Her micturition and bowel habits
were normal, appetite was normal and sleep was adequate. She does not give any
history of breast discomfort. There was no exposure to radiation. She had not
done her antenatal check up in first trimester.
Second Trimester:

There was gradual enlargement of the abdomen . She perceived the 1st
foetal movement in the fifth month around the last week of May. Her nausea and
vomiting had subsided. Her micturition and bowel habits were normal , appetite
was normal, sleep was adequate. There was no history of bleeding per vagina.
She had done her first antenatal check up on 17/05/17 and 2nd antenatel check up
on 14/06/17 in civil hospital, Bongaigaon and two doses of TT were given on
these days. She has been taking iron and folic acid tablets since 5th month of
pregnancy.
Third Trimester:

Perception of foetal movement continues. There was gradual enlargement

of abdomen. Her micturition, bowel habits, sleep and appetite were normal. She
gives no history of bleeding per vagina ,haemorrhoids ,headache ,dimness of
vision , palpitation , oedema ,fever or rash . She also complaints of fatigue since
the beginning of 7th month.

The patient complaints of pain in the lower abdomen for the last 12 hours
which was dull aching and mild in severity. The duration of pain is around 45
seconds. The pain was relieved by lying lateral position. There was no aggevating
factor of pain, no radiation and shifting of pain.
She said that there is occasional mild pain present in the lower abdomen
over the previous caesarean scar which gets aggrevated by lifting heavy objects
hard working and relieved on taking rest . There is no radiation of the pain to
other sites.

The patient also complaints of draining per vagina of mild amount for
last 12 hours which is watery without presence of blood.
Past obstetric history:

No. of Year Pregnancy Labour Mode of Place of Puerperium Baby

pregnancy events events delivery delivery

1 22/7/14 _duratio 0f _the patient -Caesarean Lower Assam normal -living

pregnancy was not in section Hospital, -date of birth
was 9months labour -type was Bongaigaon 22/07/14
10 days. -breech lower -male
_antenatally presentation segment -birth
cared caesarean weight:3 kg
_no section -age: 3years
complication (transverse) -cried at
-elective birth
-no pre- -condition at
,intra- and birth: normal
post- -condition at
operative present: alive
complication & healthy
-exclusive
breast
feeding up to
6months
-immunised
with all
vaccination
till date
Menstrual history:

She attained her menarche at 13 years. Her menstrual cycle is 28+/-

2days,regular. Duration of menstruation is 4-5days.Flow is normal , she changes
pads twice a day. There is no associated pain, no passage of clots, no white
discharge or bleeding per vagina between two cycles.

Past medical history:

There is no history of diabetes, hypertension, tuberculosis, thyroid

disorder, asthma, malaria, chronic illness, heart disease.

Past surgical history:

There is no history of other operative procedure.

Family history:
There is no history of tuberculosis, diabetes, hypertension, coagulopathies,
congenital anomalies, twin pregnancy in the family. All the family members are
enjoying good health.

Personal history:
She consumes an average Assamese diet, consisting of 3 major meals and 2
minor meals. Her appetite is normal, sleep is adequate, Her bladder and bowel
habits are normal. She is addicted to betel nut.

Contraceptive history:
The patient did not use any contraceptive methods after her last child
birth.
Drug history:
The patient has taken 100 iron and folic acid tablets since her 5th month of
pregnancy.

Allergic history:
Her allergic history is unknown.

Immunisation history:
She had taken 2 doses of TT at 5th and 6th months of pregnancy.
GENERAL EXAMINATION
The patient is alert and conscious.
Built: Adequate
Nutrition: Average
Decubitus of choice
Afebrile
Height: 150 cm
Weight: 58 kg
BMI: 25.7 kg/m2
 Pallor: Present
Icterus: Absent
Cyanosis: Absent
Oral cavity hygiene is maintained
Tongue is moist
Neck glands including thyroid not palpable
Neck veins not engorged
 Clubbing: Absent
Koilonychia: Abesnt
Oedema: Absent
 Pulse: Rate 78 bpm, regular in rhythm,
normal in volume and character, no radio
radial delay, no radio femoral delay. All
peripheral pulses are equally palpable.
Condition of arterial wall is normal
Respiratory rate: 16 bpm, rhytm is regular,
breathing pattern thoraco abdominis.
Blood pressure: 120/80 mm of Hg
CENTRAL NERVOUS SYSTEM
The patient is alert and conscious.
Systemic examination
Well oriented to time, place and person.
Higher functions are intact
Cranial nerves are functioning.
Motor function are intact.
Sensory function are intact.
Reflexes are present.
Plantar reflex is flexion
CARDIO VASCULAR SYSTEM:
Apex beat at 5th intercostal space lateral to
mid clavicular line
S1 and S2 heard.

RESPIRATORY SYSTEM:
Trachea is in midline.
Normal resonant note is elliciated over chest
wall.
Normal vesicular breath sounds are heard all
over chest
No added sounds.
 Prior to examination,verbal consent was taken,patient
was counselled and she was asked to evacuate her
bladder.
INSPECTION
Shape of the abdomen-spherical
Umbilicus is in the midline and is everted
Striae gravidarum and linea nigra are present
There is a transverse CS scar measuring about 8 cm in
length and is about 12 cm below the umbilicus
 Scar condition is healthy
No visible peristalsis , no visible pulsation
No visible fetal movement
No other visible swelling
Skin condition is healthy
PALPATION
Uterus is centralized
Fundal height is 32weeks,flanks are not full
SFH=32cm
Abdominal girth is 90 cm at the level of umbilicus
Scar tenderness is absent
2 uterine contractions palpated in 10 minutes each
contraction lasting for 45-50 seconds.
One fetal movement felt while palpating the uterus
 Fundal grip---
Broad,soft,irregular,non ballotable mass suggesting
buttock
Lateral grip---
Right side=irregular multiple knob like structures
suggesting fetal limbs
Left side=smooth,curved and uniformly resistant feel
suggesting fetal back
 First pelvic grip---Hard,smooth,globular,ballotable
mass suggesting head.
Head is in flexed attitude , presenting part is
vertex,Left occipito-anterior position,not engaged.
Second pelvic grip =findings of first pelvic grip are
confirmed.
Auscultation
FHR is 140 bpm ,regular and clear in intensity , in the
left spino-umbilical line.
P/V findings
Os is 2 cm
Cervix is 20% effaced,posterior
Liquor is clear
Provisional diagnosis
The patient Rita Das of age 24 years is provisionally
diagnosed to be a case of G2P1L1 post CS pregnancy at
31 weeks 6 days of gestation with single live fetus
in cephalic presentation with FHR 140 bpm,with
preterm premature rupture of membrane in latent
labor.
 INVESTIGATIONS AND ASSESSMENT
Mandatory regular antenatal checkup
History of pain or tenderness over scar or any h/o
vaginal bleeding
ULTRASOUND :
Single live intra uterine pregnancy in cephalic presentation.
Placenta anterior body extending to the right lateral wall ,
not low lying.
Liquor- adequate
Fetal heart rate- 144 bpm
Fetal maturity- 39 weeks 4 days
EDD-
No gross congenital anomaly is seen.
Investigation of blood:-
WBC- 10.53x 10^3/ul
RBC 3.85 x 10^6/ul
Hb- 9 gm/dl
Platelet- 2 lac/ul
RBS- 79 mg/dl
S. Creatinine - 0.9 mg/dl
TSH- 5.02
Liver function test:-
Total bilirubin-0.9 mg/dl
Direct bilirubin-0.3 mg/dl
Indirect bilirubin-0.6 mg/dl
SGOT-78 u/l
SGPT-36 u/l
Alkaline phosphate -312 IU/l
Total protein-6.5gm/dl
DIAGNOSIS
The patient Rita Das 24 years old female is finally
diagnosed to be a case of post-caesarian section
pregnancy with G2P1L1 with 31 weeks 6 days of
gestation with cephalic presentation , longitudinal lie,
head is not engaged with PPROM in latent labour
 Options for a patient
with previous cesarean
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 (60 to 80%)
Failed TOLAC - Emergency cesarean Delivery
 ELECTIVE
HOSPITALIZATION

LOWER
CLASSICAL/
SEGMENT
HYSTERECTOMY
TRANSVERSE
SCAR
SCAR

ELECTIVE
ELECTIVE VAGINAL
C.S. AT 38
C.S. DELIVERY
WEEKS
 Hospitalization
ELECTIVE HOSPITALIZATION:-

LSCS scar Hospitalization at 38 weeks

Classical CS at 36 weeks due to possibility of

rupture of scar in pregnancy
EMERGENCY HOSPITALIZATION

ONSET OF LABOUR

SCAR RUPTURE

OBSTETRIC
COMPLICATIONS
 Elective caesarean
section

If VBAC is contraindicated / if patient refuses

Timing

if fetal maturity is sure 39wks

if not spontaneous labor awaited
previous classical CS 38 wks
Vaginal Birth After C-Section
(VBAC)
Once a C-section is not always a C-section
If the Patient had a cesarean delivery before, she may
be able to deliver her next baby vaginally. This is called
vaginal birth after cesarean, or VBAC
Selection of candidates for
VBAC
 Selection of cases of VBAC

Previous history
1. Type of prior uterine incision LS transverse incision
2. Prior indication success rate is more when prior
indication is non-recurrent (breech/fetal
distress/placenta praevia/ 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 18 months to heal the scar, so a gap of 18-24

months is necessary
 Present pregnancy

1) No medical / obstetric complication

2) Average sized baby

3) Vertex presentation

4) No CPD
 Contraindications
Previous classical incision

Previous two LSCS

Pelvis contracted or suspected CPD

Previous inverted T/ extension of incision

Malpresentations

Medical /obstetric complication

Multiple pregnancy

Patients refusal to undergo trial

History of prior uterine rupture

Vaginal Birth After Cesarean [VBAC]

Rupture of uterus during pregnancy or labor can

be catastrophic, therefore VBAC should be
attempted in a well equipped institution only
Where services of Obstetrician,
Anaesthesiologist, Neonatologist are available
and safe blood can be transfused to the patient if
required

11/12/2017 hcb 44
Management
Informed consent
Monitoring
Delivery
Signs of Scar dehiscence
MANAGEMENT OF LABOUR &
DELIVERY
Iv-Ringer solution
Blood sample Hb%, grouping, cross matching
Spontaneous onset of labor desired
Monitoring
Epidural analgesia
Augmentation by oxytocin selectively & judiciously
Prophylactic forceps or ventouse
Exploration of uterus.
Delivery
Cut short the second stage with outlet
forceps/vacuum

Look for excessive bleeding in third stage - sign of

scar rupture

If bleeding is excessive, maternal hypotension inspite

of well contracted uterus- emergency laparotomy

Observe for 4-6hrs in labor ward

STERILISATION
Increasing risk after each operation

During third time CS strerilization should be

considered unless there is sufficiently strong

reason to withhold it
 Predicting the
success v/s failure
of Trial of Labor
Increased probability of success of TOLAC
Prior vaginal birth
Spontaneous onset of Labor

Decreased probability of success

Recurrent indication for initial cesarean delivery
( Dystocia, CPD)
Increased maternal Age
Nonwhite ethnicity
Gestational age > 40 weeks
Maternal obesity
Pre-eclampsia
Short interpregnancy interval
Increased neonatal birth weight
Maternal benefits
VBAC
60-80% chance of success
If successful, shorter hospital stay
Increased likelihood of vaginal
delivery in future pregnancies
Decrease risk of abnormal
placentation
ERCD
Able to plan the delivery on a known
date
Lower risk of vaginal tears & no
worsening of pelvic floor support
Surgical sterilization can be done at
the same time
Lower risk of transfusion (1%) &
endometritis (1.8%) as compared to
failed TOLAC
Neonatal benefits
VBAC ERCD

<1% risk of transient respiratory Avoids risk of antepartum still

morbidity (<ERCD) birth since delivery is undertaken
at the commencement of 39th
week
Maternal risks
VBAC
Chance of instrumental delivery &
perineal tear
Failed TOLAC increases maternal
morbidity
Risk of uterine scar rupture
Chance of emergency cesarean delivery
Higher risk of blood transfusion(1.7%) &
endometritis(2%)
ERCD
Increases likelihood of cesarean delivery
in future pregnancy
Longer hospital stay
Chances of serious surgical
complications like bladder injury
Increased risk of surgical complications
with each subsequent cesarean delivery
due to adhesions, placenta
praevia/accreta
Clinical signs of uterine rupture
Most reliable First sign is - Non reassuring fetal heart
tracing
Most Specific sign is - Persistent variable fetal heart
deceleration.
0ther signs
Maternal tachycardia,
Hypotension,
Hematuria,
Pain over previous incision site
Vaginal bleeding
Suprapubic pain persisting between contraction
Dramatic loss of station
MANAGEMENT OF RUPTURED
UTERUS DURING DELIVERY
Any of three procedures may be adopted followed by
laparotomy
- hysterectomy
- repair
- repair and sterilization