Managing women with previous CS

VBAC :Should you or should you not attempt? drzainalabidinhanafiah

introduction
Widespread public and professional concern about increase rate of CS
(more morbidity/mortality than VD)

CS rate women with previous scar > high risk gp of women. Choice of delivery mode appear simple but actually it is a complex decision since available evidence can be confusing. Central issue of VBAC is UTERINE

Some definitions
Planned VBAC: refers to any woman who has prior CS who plans to deliver vaginally rather than elective repeat CS (ERCS). Successful VBAC: vaginal delivery after planned VBAC Failed VBAC: delivery by emergency CS during labour. Uterine rupture: disruption of uterine muscle extending to and involving serosa Uterine dehiscence: disruption of uterine muscle with intact serosa.

Plan of care for singleton uncomplicated previous LSCS

Items to be discussed to determine mode of delivery.

Items Special considerations Patient understanding of Her attitude towards the risk of rare maternal/perinatal risk & benefits of but serious adverse outcomes VBAC compared to ERCS Any contraindication to VBAC
Placenta previa, malpresentation, obstructing fibroids, medical disorders, assessment of previous CS; any complications, classical CS, 2 CS, previous uterine rupture would be absolute contraindication.

Likelihood of successful VBAC Her plan for future pregnancy Her personal preference and motivation to achieve VD or ERCS

With previous VD or successful VBAC

Risks and benefits of opting for VBAC or ERCS

Planned VBAC
Mother benefits: about 70% chances of success If successful, shorter hospital stay and convalescence Increase chances of future pregnancies may be delivered vaginally

ERCS at 39 weeks
Able to plan delivery date Lower risk of transfusion & endometritis compared to women undergone emergency CS due to failed VBAC Almost zero risk of scar rupture No risk of vaginal tear, weak pelvic floor and incontinence Can undergo tubal ligation at same sitting.

Mother risks: about 0.5% risk of scar rupture assoc with maternal 0.1-2% risk of surgical complication such as injury to & fetal morbidity/mortality bladder Up to 30% of emergency CS 10-15% chance instrumental delivery/perineal tear Higher risk of transfusion and endometritis Infant benefits: low risk of TTN Long stay and convalescence Future pregnancies require CS Increase risk of surgical complication with subsequent CS Avoid stillbirth if delivery is undertaken at 39 weeks Low risk of delivery related perinatal death or HIE at delivery Infant risks: slightly high risk of stillbirth beyond 39weeks while waiting for spontaneous birth Small but higher risk of delivery related perinatal death Small but higher risk of HIE during labour. 1-3% risk TTN (6% if deliver by 38 instead of 39 weeks)

Contraindication to VBAC

Previous uterine incision: previous rupture, previous classical incision (2-9% risk), 2 or more LSCS. Previous inverted T or J incision. ?previous myomectomy. Other factors: placenta previa (need to exclude accreta, increta or percreta), any medical/obst condition precluding VD, patient refusal, no facilities for em CS,

Likelihood of successful VBAC

Successful: previous VD, previous VBAC (assoc with 80% success), previous CS for malpresentation, multiple pregnancy. Unsuccessful: induced labour, no previous VD, BMI >30, previous CS for obstructed labour, VBAC after 41 weeks, macrosomia, no epidural, previous preterm delivery, cervical dilatation <4cm on admission, <2yrs from previous CS, advance maternal age, short stature.

Intrapartum care during planned VBAC

Reconfirm what has been counseled during antenatal that the woman understand and consent to the risks. Document in BHT as part of informed consent.

1. Delivery setting
Adequately staffed and equipped delivery suite. With facilities for continuous intrapartum care and monitoring. Availability for immediate CS and neonatal intensive care.

2. Is epidural allowed?
Concerns of epidural might mask signs and Sx of uterine rupture. Comparable rate of successful VBAC. Women requesting epidural should be informed about risk of longer second stage and higher chance of instrumental delivery

3. Monitoring in labour
As for all high risk cases, continuous monitoring is necessary, preferable one to one care, regular cervix assessment (no less than 4hrly) Extra vigilance for clinical features of scar rupture, abnormal CTG, sudden severe abd
pain, acute onset of abd tenderness, vaginal bleeding, haematuria, sudden reduce in uterine activity, maternal tachy, low BP, sudden loss of station of presenting part.

Early diagnosis is essential to reduce assoc morbidity/mortality

 Not absolute but must be cautioned since risks are higher. Decision must be made at consultant level, careful assessment for indication, to involve the patient in decision making. PGs >non PGs, restrict dose, not to exceed recommended limit. No misoprostol. Non PGs may be tried e.g foley catheter

Is induction or augmentation ok?

Induction and augmentation

Induced Uterine rupture 102:10000 (1%) Augment Spont overall 87:10000 36:10000 69:10000 (0.9%) (0.4%) (0.7%)

PGs 140:10000 (1.4%)*

Non PGs 89: 10000 (0.9%)

CS

33%

26%

19%

27%

Augmentation and slow labour

Should be started following careful assessment, maternal counseling, consultant-led. Oxytocin is titrated to max contraction 4:10, with max infusion rate 20mU/min Serial cervical assessment preferably by same person to assess progress: unscarred uterus, slow progress in 1st
stage = dilatation <2cm in 4 hrs, amniotomy performed if membrane still intact then rpt VE in 2 hrs if <1cm then oxytocin is commenced, review in 4 hrs and if <2cm dilate to consider CS, but in previous scar, between 2-4hours of oxytocin.

If there is progress, augmentation may continue and VE is performed 4Hrly.

Post dates
Usual to wait for spontaneous labour between 39-41 weeks. >41 weeks IOL is offered (shown to reduce PNMR without increase in CS) Previous CS by 41 weeks to counsel again VBAC vs. ERCS Favourable factors such as favourable cervix and previous succesful VD.

For women who refuse VBAC

The timing for ERCS is at 39 weeks in order to minimize the risk of respiratory morbidity

Among advice to women who refuse ERCS

Risk of praevia increases with more CS (0.63% in previous 1 scar, 0.72% in 2 scars) Coexisting accreta with anterior praevia also increases with number of repeat CS (between 3% in second CS up to 40% in 4th CS) Slightly higher incidence of placental abruption. Injury to bowel, bladder and ureter. Ileus Need for post op ventilation ICU admission Hysterectomy Blood transfusion Longer operative time and hospital stay.

Placenta praevia and accreta All women with previous scar identified to hv low lying placenta will be rescan at 3236 weeks provided they are asymptomatic. Especially those with anterior praevia. Preop identification of accreta with US & color doppler and MRI Once confirmed, specific management strategies involving multidiscipline clinical expertise.

VBAC in special circumstances

Preterm VBAC: similar success rate as term VBAC Rate of uterine rupture 34:10,000 vs. 74:10,000. Similar perinatal outcomes with preterm VBAC and preterm ERCS. Twin VBAC: small studies show similar success rate

Fetal macrosomia
Lower success rate of VBAC for pregnancies with infants > 4000gm or more. Larger birth weight in planned VBAC compared previous birth weight.

Short interdelivery interval

A shorter interdelivery interval (below 12 months) from previous CS is associated with 2-3 fold increased risk of uterine rupture, major maternal morbidity and blood transfusion.

VBAC is perhaps not for obese women

Even for women without scar, the likelihood for CS is higher thus more so in women with previous LSCS. Most obstetrician discouraged VBAC in women with BMI >40

VBAC and Law

In the US, more than 90% previous scar undergone ERCS, why is this so??? In reality many hospitals and obstetrician no longer performing VBAC. Main reason: risk of adverse outcomes and subsequent litigation. Main risk: uterine rupture (0.7% vs 0.00022%) Very high risk for perinatal death and

What choice do obstetricians have?

Simplest choice is: ban VBAC!!!, no VBAC no uterine rupture therefore no lawsuit! Nevertheless most obstetricians do not want to give up VBAC (we see

stricter guidelines emerging to ensure safety and reduce potential lawsuit in case of bad outcome).

The facts remain, unless we accurately and individually assess the risks, VBAC is destined to fade

 Stricter guidelines such as: VBAC for women with no co morbidities, had prior VBAC or VD at term, spontaneous labour, no augmentation, normal CTG and disallow women who are obese, post date, term PROM, unengaged head, unfavourable cervix. But despite adequate informed consent, standard of care fulfilled, guidelines followed, well documented events, still if bad outcomes happen,

 Ultimately it is up to us, not the court to determine whether VBAC should stay or go. We have to find ways to resolve this dilemma which I doubt we will in next 5-10 years to come. Otherwise VBAC will disappear as what has happened to vaginal breech delivery.actually may not be a bad thing.