1

DR. H. K. SUHEIMI BLOG

D A L A M B L O G I N I B I S A D I B A C A T U L I S A N - T U L I S A N D R . H . K . S U H E I M I . . .
L A B E L
Kepribadian Minang [Serial] (15)
Ketika Pasien Bertutur [Serial] (6)
Pepatah [Serial] (62)

M I N G G U 0 8 M A R E T 2 0 0 9
Trs:


--- Pada Sab, 7/3/09, Engga Lift <enggaobgyn@yahoo.com>menulis:

Dari: Engga Lift <enggaobgyn@yahoo.com>
Topik:
Kepada: ksuheimi@yahoo.com
Tanggal: Sabtu, 7 Maret, 2009, 6:00 PM











2






UNIVERSITAS ANDALAS


ARREST OF DESCENT


PRESENTASI KASUS

Oleh:
Selly Septina
Peserta PPDS


Pembimbing :
Dr. H. MUCHLIS HASAN , SpOG



BAGIAN/SMF OBSTETRI DAN GINEKOLOGI
FAKULTAS KEDOKTERAN UNAND
RS Dr. M.DJAMIL PADANG
3


2009
BAB I
PENDAHULUAN

"Sekali seksio sesarea akan selalu seksio sesarea" kalimat ini disampaikan oleh DR.
Edward B. Cragin tahun 1916 pada New York Association of Obstetricians & Gynecologists.
Diktum ini diterima selama bertahun-tahun secara luas di berbagai negara dengan dasar
pertimbangannya adalah tingginya frekuensi dehisensi ataupun ruptura uteri pada sikatrik bekas
seksio sesarea. Keadaan ini mencerminkan pengelolaan pasien-pasien oleh ahli obstetrik pada
masa lalu .
(Lavin JP, et al, 1982, Caughey AB, Mann S, 2001 )

United States Public Health Service 1991 mengatakan peningkatan progresif seksio
sesarea di Amerika Serikat terjadi pada tahun 1965 1988, dari 4,5 % seluruh kelahiran menjadi
hampir 25 %. Belizan dan kawan-kawan 1999 menyatakan hal ini juga terjadi di Amerika
latin.
( Cunningham FG, 2001)
. Angka kejadian seksio sesarea di Indonesia masih merupakan data
Rumah Sakit seperti pada tahun 1987 RSCM Jakarta 23,2 % dan RSUD Dr. Sutomo Surabaya
17,6 %
(Samil 1988)
. Di RSUD Dr. Pirngadi Medan angka kejadian seksio sesarea tahun 1990
adalah sebesar 16,6 %,
(Rasyid, 1992)
sedangkan di RSUP Dr. M. Djamil Padang tahun 1990 adalah
13,37 %
(Sulaini, 1991)
dan Abdullah F tahun Oktober 1997 Maret 1998 sebesar 27,95 %.
( Abdullah F,
1998)
Tahun 2000 dan 2001 jumlah seksio sesarea di RSUP Dr. M. Djamil Padang adalah 22,46
% dan 23,33 %
(Medical record)

Melihat peningkatan angka kejadian seksio sesarea United States Public Health Service,
melalui Consensus Development Conference on Cesarea Child Birth pada tahun 1980
merekomendasikan persalinan pervaginam pada bekas seksio sesarea dengan insisi uterus
transversal pada segmen bawah rahim adalah tindakan yang aman dan dapat diterima dalam
rangka menurunkan angka kejadian seksio sesarea pada tahun 2000 menjadi 15 %.
( Clarke SC, Taffel
S, 1995, Scott JR. 1997, Cunningham FG, 2001)
.
Pada tahun 1989 National Institute of Health dan American College of Obstetricans and
Gynekologists mengeluarkan statemen, yang menganjurkan para ahli obstetri untuk mendukung
trial of labor pada pasien-pasien yang telah mengalami seksio sesarea sebelumnya, dimana
persalinan pervaginam setelah seksio sesarea merupakan tindakan yang aman sebagai pengganti
seksio sesarea ulangan.
( O'Grady JP, et al, 1995, Caughey AB, Mann S, 2001)

Penanganan persalinan pada bekas seksio sesarea dapat dengan melakukan persalinan
pervaginam / Vaginal Birth After Cesarean, jika gagal dilanjutkan dengan seksio sesarea darurat
atau dengan seksio sesarea ulangan.
(Toth P.P, Jothivijayarani A, 1996)

Keuntungan dan kerugian mengulangi seksio sesarea dan mencoba persalinan
pervaginam pada pasien dengan bekas seksio sesarea harus benar-benar dipertimbangkan..
( Hill
DA, 2002 )
. Persalinan pervaginam dilakukan apabila syarat-syarat " Trial of scar " terpenuhi.
(Chua S,
Arulkumaran, S 1997
,
Hill DA, 2002 )
..
4


Flamm & Geiger dan Weinstein dkk telah menentukan beberapa faktor yang
berhubungan dengan keberhasilan persalinan pervaginam pada bekas seksio sesarea seperti
faktor ; umur, riwayat persalinan pervaginam, indikasi seksio sesarea sebelumnya, dan keadaan
serviks pada waktu masuk Rumah Sakit . Dari faktor faktor ini mereka mengembangkan suatu
sistem skoring untuk memprediksi keberhasilan persalinan pervaginam, semakin tinggi skoring
pasien bekas seksio sesarea maka keberhasilan persalinan pervaginam akan semakin besar.
(Weinstein D, 1996, Flamm BL, Geiger AM, 1997)

Berikut ini akan dibahas suatu kasus, seorang pasien wanita berusia 33 tahun, masuk RS.
M. Jamil tanggal 4 November 2008 jam 15.00 wib dengan diagnosa G2P1A0H1 gravid aterm 39
40 minggu + Bekas SC + PRM, anak hidup tunggal intra uterin letak kepala H I-II. Kemudian
direncanakan melakukan drip induksi. Setelah dilakukan induksi persalinan pada kolf kedua,
akhirnya pasien melahirkan bayi perempuan () secara spontan dengan BB : 3576 gr, PB : 50
cm, dan A/S : 8/9.
Setelah dirawat 2 hari di kamar rawat kebidanan, pasien pulang dalam keadaan baik.










BAB II
K A S U S

Identitas Pasien
Nama : Nurtinis Nama suami : Yusuf
Umur : 33 thn Umur : 33 thn
Pendidikan : tamat SD Pendidikan : tamat SMP
5


Pekerjaan : ibu RT Pekerjaan : buruh
Alamat : Kayu Aro, Bungus
Nomor MR : 61 52 45

Anamnesis
Seorang pasien wanita umur 33 tahun masuk ke Kamar Bersalin IGD RS M Jamil pada
tanggal 04 November 2008 jam 15.00 WIB, dengan keluhan utama : Keluar air-air yang banyak
dari kemaluan sejak 7 jam yang lalu

RI WAYAT P E NYAKI T S E KARANG
Keluar air-air yang banyak dari kemaluan sejak 7 jam yang lalu membasahi 1
helai kain sarung, bau amis, warna jernih
Nyeri pinggang menajalar ke ari-ari tidak ada
Keluar lendir campur darah dari kemaluan tidak ada
Keluar darah yang banyak dari kemaluan tidak ada
Tidak haid sejak 9 bulan yang lalu.
HPHT : 01-02-08 TP :08-11-08
Gerak anak dirasakan sejak 5 bulan yang lalu
RHM : mual (-), muntah (-), perdarahan (-).
PNC : kontrol ke bidan
RHT : mual (-), muntah (-), perdarahan (-).
Riwayat menstruasi : Menars usia 13 tahun, teratur 1x setiap 28 hari, lamanya 5-
7 hari, banyaknya 2-3 kali ganti duk/hari, nyeri haid (-).
RI WAYAT P E NYAKI T DAHUL U
Tidak pernah menderita penyakit jantung, paru, hati, ginjal, diabetes melitus dan hipertensi.

6


RI WAYAT P E NYAKI T KE L UARGA
Tidak ada anggota keluarga yang menderita penyakit keturunan, menular dan kejiwaan.

Riwayat pekerjaan, sosial ekonomi, kejiwaan dan kebiasaan :
Riwayat perkawinan 1 x tahun 2005
Riwayat kehamilan / abortus / persalinan : 2 / 0 / 1
1. 2006, laki-laki, 3000 gr, SC ai PRM lama, Dokter, Rs Swasta Hidup, Luka OP
sembuh 7 hr
2. sekarang
Riwayat Kontrasepsi : Tidak ada
Riwayat Imunisasi : TT 1x di bidan

P E ME RI KS AAN UMUM
Keadaan umum : Sedang Berat badan : 52 kg
Kesadaran : CMC Tinggi badan :142 cm
Tekanan darah : 110/70
Nadi : 84x/menit
Suhu : 37C
Pernafasan : 20 x / menit
Gizi : sedang
Edema : -/-
Anemia : -/-

- Kulit : tidak sianosis
- KGB : tidak membesar
7


- Kepala : tidak ada kelainan
- Rambut : tidak ada kelainan
- Mata : konjungtiva tak anemis, sklera tak ikterik
- Telinga : tidak ada kelainan
- Hidung : tidak ada kelainan
- Tenggorokan : tidak ada kelainan
- Gigi dan mulut : caries dentis (-)
- Leher : JVP 5 - 2 cmH
2
O
kelenjar tiroid tidak membesar
- Dada : Paru : I : simetris, kanan = kiri
Pa : fremitus, kanan = kiri
Pe : sonor
A : vesikuler normal, ronkhi -, wheezing -
Jantung : I : Iktus cordis tidak terlihat
Pa : Iktus cordis teraba 1 jari LMCS RIC V
Pe : Batas jantung dalam batas normal
A : Irama reguler, bising (-)
- Perut : Status Obstetrikus
- Punggung : Tidak ada kelainan
- Alat kelamin : Status Obstetrikus
- Anus : RT tidak dilakukan
- Anggota gerak : Rf +/+, Rp -/-, oedem -/-
Status Obstetrikus
Muka : Kloasma Gravidarum (+)
8


Mamae : Membesar, tegang, A/P hiperpigmentasi, kolostrum (+)
Abdomen :
Inspeksi : Perut tampak membuncit sesuai usia kehamilan aterm
L/M hiperpigmentasi,sikatrix (+)bekas sc
Palpasi : L1: FUT 3 jari bawah prosesus xipoideus.
Teraba massa besar, lunak, noduler.
L2: Teraba tahanan terbesar sebelah kiri
Teraba bagian-bagian kecil janin di sebelah kanan
L3: Teraba massa bulat,keras
L4: Bagian terbawah janin sudah masuk PAP
TFU = 34 cm TBA = 3255 gram
His = (-)
Perkusi : Timpani
Auskultasi: BU (+) N BJA : 150 x / menit

Genitalia
Inspeksi: V/U tenang
Inspeculo :
Vagina : tumor (-), laserasi (-), fluxus (+), tampak cairan menumpuk di
fornix posterior
Portio : MP, ukuran sebesar jempol kaki dewasa, tumor (-), laserasi (-),
fluxus (+) tampak cairan mengalir dari canalis servikalis, LT (+)
VT : 1 jari
Portio tebal 1 cm, medial, lunak
Ketuban (-) sisa jernih
9


Teraba kepala H
I-II

Ukuran panggul dalam :
Promontorium tidak bisa dinilai
Linea inominata tidak bisa dinilai
Os sakrum cekung
Dinding samping panggul lurus
Spina ischiadika tidak menonjol
Os koksigeus mudah digerakkan
Arkus pubis > 90
0

Ukuran panggul luar:
Distansia inter tuberum dapat dilalui satu tinju dewasa (>10,5cm)
Kesan : panggul luas
Diagnosa
G
2
P
1
A
0
H
1
gravid aterm 39 - 40 minggu + Bekas SC + PRM
Anak hidup tunggal intra uterine letak kepala H I-II
Sikap
Kontrol KU, VS, BJA
Antibiotika (skin tes)
Darah PMI 2 kolf
Drip Induksi

Rencana
Partus pervaginam

Laboratorium
10


Darah : Hb : 12 gr%
Leukosit : 15.700/mm
3

Ht : 37 %
Trombosit : 274.000/ mm
3


Jam 15.00 wib
Diagnosa
G
2
P
1
A
0
H
01
gravid aterm 39 - 40 minggu + Bekas SC + PRM
Anak hidup tunggal intra uterine letak kepala H I-II
Sikap :
Kontrol KU, VS, BJA
Antibiotika (skin tes)
Darah PMI 2 kolf
Rencana :
Drip Induksi
Lapor Konsulen Acc Drip Induksi
Jam 15.00 wib
Dimulai drip induksi dengan oksitosin 5 iu dalam 500 cc RL dimulai 10 tetes / mnt
Dinaikkan 5 tetes setiap 30 mnt sampai his adekuat (max 60 tetes / mnt)

Jam 19.15 wib
Selesai drip induksi kolf I
A/ -Nyeri pinggang menjalar keari-ari(+)
-Gerak anak (+)
PF/ KU : sedang; Kesadaran : CMC; TD : 110/70 mmHg,
11


ND : 84x/mnt; Nfs : 20 x/mnt; Suhu : af,
His : 4-5/40"/K ; BJA : 140x/menit
Genitalia : I : V/U Tenang
VT : 4-5 cm
Ketuban (-) sisa jernih
Teraba kepala UUK kimel H
II-III

D/ G
2
P
1
A
0
H
1
parturient aterm 39-40 minggu kala I fase aktif + Bekas SC
Anak hidup tunggal intra uterine letak kepala UUK kimel H
II-III

S/ Kontrol KU, VS, BJA, His
Lanjutkan drip induksi kolf II
R/ Partus pervaginam

Jam 19.30 wib
Dimulai drip induksi kolf II dengan oksitosin 10 iu dalam 500 cc RL 30 tetes permenit konstan
Jam 20.15 wib
A/ - Pasien merasa kesakitan dan ingin mengedan
- Gerak anak (+)
PF/ KU : sedang, Kesadaran : CMC, TD : 110/70 mmHg, ND : 84x/mnt,
Nfs : 24 x/mnt, Suhu : af
His : 2-3'/50''/K, BJA : 140x/menit
Genitalia : I : V/U Tenang
VT : lengkap
ket (-) sisa jernih
teraba kepala UUK depan H
III-IV

D/ G
2
P
1
A
0
H
1
parturient aterm 39-40 minggu kala II + bekas SC
Anak hidup tunggal intra uterin letkep UUK depan H
III-IV

S/ - Kontrol KU, VS, BJA, His
- pimpin mengedan
12


R/ Partus pervaginam

Jam 20.30 WIB
Lahir seorang bayi perempuan (), secara Spontan dengan:
Berat Badan : 3576 gram
Panjang Badan : 50 Cm
Apgar Score : 8/9
Plasenta lahir spontan, lengkap, 1 buah, ukuran 18x17x2,5 cm, berat 500 gram, panjang tali
pusat 50 cm, insersi parasentral.
Luka episiotomi dijahit dan dirawat
Perdarahan selama persalinan 100 cc
D/ P
2
A
0
H
2
post partus maturus spontan
Anak baik, ibu baik
S/ Awasi kala IV

FOLLOW UP
Tanggal 05-11- 08 jam 7.00 wib
An/ Demam (-), sesak (-), PPV(-), ASI (-), BAK (+), BAB (-)
PF/ KU Kes TD Nd Nfs T
Sedang CMC 130/80 84x/m 24x/m af
Mata : konjungtiva tidak anemis, sklera tidak ikterik
Abdomen: I : tampak sedikit membuncit
Pa : Fundus uteri teraba 2 jari bawah pusat
Kontraksi (+) baik, NT (-), NL (-), DM (-)
Pk: Tympani
Aus : BU (+) N
13


Genitalia: I :V/U tenang, PPV (-)
D/ Nifas Hr I, P2A0H2 post partus maturus spontan
Anak-ibu baik
S/ Kontrol KU,VS, PPV.
Breast care
Diet TKTP
Th/ Amoxicillin 3x500 mg
Antalgin 3 x 500 mg
SF 1x1 tab
Gentamicin zalf

Tanggal 06-11- 08 jam 7.00 wib
An/ Demam (-), sesak (-), PPV(-), ASI (-), BAK (+), BAB (-)
PF/ KU Kes TD Nd Nfs T
Sedang CMC 120/80 84x/mnt 24x/mnt af
Mata : konjungtiva tidak anemis, sklera tidak ikterik
Abdomen: I : tampak sedikit membuncit
Pa : Fundus uteri teraba 3 jari bawah pusat
Kontraksi (+) baik, NT (-), NL (-), DM (-)
Pk: Tympani
Aus : BU (+) N
Genitalia: I :V/U tenang, PPV (-)
D/ Nifas Hr II, P2A0H2 post partus maturus spontan
Anak-ibu baik
S/ Kontrol KU,VS, PPV.
14


Breast care
Diet TKTP
Th/ Amoxicillin 3x500 mg
Antalgin 3 x 500 mg
SF 1x1 tab
Gentamicin zalf
R/ Pulang


BAB III
TINJAUAN PUSTAKA

Seksio sesarea adalah suatu tindakan untuk melahirkan janin dengan pembedahan
dinding perut (laparatomi) dan dinding uterus (histerotomi). Definisi ini tidak termasuk
pengangkatan fetus dari dalam rongga abdomen pada kasus-kasus ruptura uteri atau pada kasus
kehamilan abdominal. Dewasa ini tindakan ini jauh lebih aman dari pada dahulu berhubung
sudah tersedia obat antibiotika, transfusi darah, teknik operasi yang lebih sempurna dan anastesi
yang sudah baik.
( Husodo L, 1999, Cunningham 2001)

Sekarang ini ada kecendrungan untuk melakukan seksio sesarea tanpa dasar yang cukup
kuat. Perlu diingat bahwa seorang ibu yang telah mengalami seksio sesarea merupakan
seseorang yang mempunyai parut dalam uterus dan tiap kehamilan serta persalinan berikutnya
memerlukan pengawasan yang lebih cermat.
( Husodo L, 1999)

Seksio sesarea ulang dan distosia merupakan penyebab tertinggi seksio sesarea di
Amerika Serikat dan negara industri lainnya..

Secara keseluruhan angka persalinan dengan
seksio sesarea di Amerika Serikat meningkat secara cepat tiap tahunnya. United States Public
Health Service 1991 mengatakan peningkatan progresif seksio sesarea di Amerika Serikat terjadi
pada tahun 1965 sampai dengan tahun 1988, dari 4,5 % seluruh kelahiran menjadi hampir 25 %.

(Cunningham FG,2001)

Kira-kira 25 % bayi yang dilahirkan di berbagai negara adalah dengan seksio sesarea, hal
ini menimbulkan situasi dimana seorang ibu dengan bekas seksio sesarea harus memilih
mengulangi seksio sesarea atau dengan cara persalinan pervaginam pada kehamilan
berikutnya.
(Golber B,2000, Hill DA. MD.. 2001)

Ada banyak alasan kenapa orang menginginkan persalinan pervaginam setelah seksio
sesarea, mungkin karena alasan medis dan emosional dan alasan lain karena uang. Pada
15


persalinan pervaginam kesembuhan post partum lebih cepat, resiko infeksi lebih sedikit,
kehilangan darah lebih sedikit dan menyusui bayi lebih mudah setelah persalinan pervaginam.
Banyak keuntungan bagi ibu dan bayi. Karena alasan-alasan ini, wanita yang melahirkan
dengan seksio sesarea sebelumnya memikirkan persalinan alami (persalinan pervaginam)
untuk persalinan selanjutnya. .
( Golberg B, 2000 )

Melihat peningkatan angka kejadian seksio sesarea United States Public Health Service,
melalui Consensus Development Conference on Cesarea Child Birth pada tahun 1980
menyatakan bahwa persalinan pervaginam bekas seksio sesarea dengan insisi uterus transversal
pada segmen bawah rahim adalah tindakan yang aman dan dapat diterima dalam rangka
menurunkan angka kejadian seksio sesarea pada tahun 2000 menjadi 15 %.
( Clarke SC, Taffel S, 1995,
Scott JR. 1997, Cunningham FG, 2001)
.
Pada tahun 1989 National Institute of Health dan American College of Obstetricans and
Gynekologists mengeluarkan statemen, yang menganjurkan para ahli obstetri untuk mendukung
"trial of labor" pada pasien-pasien yang telah mengalami seksio sesarea sebelumnya, dimana
persalinan pervaginam setelah seksio sesarea merupakan tindakan yang aman sebagai pengganti
seksio sesarea ulangan.
( O'Grady JP, et al, 1995, Caughey AB, Mann S, 2001)

Ada keuntungan dan kerugian antara mengulangi seksio sesarea dan mencoba persalinan
pervaginam pada pasien bekas seksio sesarea. Jadi harus benar-benar dipertimbangkan dalam
mengambil keputusan yang tepat untuk pasien bekas seksio sesarea. Standar pelayanan medis
melarang wanita dengan riwayat seksio sesarea klasik untuk partus pervaginam karena
kemungkinan terjadinya ruptra uteri tinggi, pada pasien ini harus mengulang seksio sesarea
setiap kehamilannya.
(Hill DA, 2002)

Berbagai penelitian mendukung rekomendasi ini dan berhasil melahirkan
pervaginam sampai 80% pada pasien bekas seksio sesarea yang diseleksi. 20-30% yang
tidak berhasil melahirkan pervaginam, dilakukan seksio sesarea, karena terdapat resiko
untuk dilanjutkan untuk persalinan pervaginam. Dari berbagai penelitian didapat bahwa resiko
persalinan pervaginam pada bekas seksio sesarea lebih rendah dibandingkan dengan
dilakukan seksio sesarea kembali. Pada kenyataannya berbagai penelitian memperlihatkan
bahwa tidak terdapat peningkatan angka kesakitan atau kematian ibu dan anak dengan
melakukan persalinan pervaginam pada pasien bekas seksio sesarea .
( Golberg B, MD, 2000 )


A. Frekuensi
Di Amerika pada tahun 1990 angka kejadian persalinan pervaginam bekas seksio sesarea
adalah 19,5%, di Norwegia 56,2% dan di Swedia 32,9%.
Tahun 1996 persalinan pervaginam bekas seksio sesarea di USA adalah sebesar 28 %
(Chua S,
Arulkumaran S, 1997, Cunningham FG, 2001)


Angka persalinan pervaginam bekas seksio sesarea di Indonesia masih merupakan angka
kejadian di rumah sakit. Di RSUP Dr. M. Djamil Padang tahun 1990 Sulaini P. mendapatkan 68
(33,99%) persalinan pevaginam dari 203 pasien bekas seksio sesarea. Penelitian Abdullah F,
selama 6 bulan (Oktober 1997-Maret1998) di RSUP Dr. M. Djamil Padang terdapat 74 (26.71
%) persalinan pervaginam dari 277 persalinan bekas seksio sesarea.

16


B. Prasyarat yang harus dipenuhi
Panduan dari American College of Obstetricans and Gynekologists pada tahun 1999
tentang persalinan pervaginam pada pasien bekas seksio sesarea atau yang dikenal dengan trial
of scar memerlukan kehadiran seorang dokter ahli kebidanan, seorang ahli anastesi dan staf yang
mempunyai keahlian dalam hal persalinan dengan seksio sesarea emergensi. Sebagai
penunjangnya kamar operasi dan staf disiagakan, darah yang telah di-crossmatch disiapkan dan
alat monitor denyut jantung janin manual ataupun elektronik harus tersedia.
(Whiteside DC, 1983, Caughey
AB, Mann S, 2001)

Pada kebanyakan senter merekomendasikan pada setiap unit persalinan yang melakukan
persalinan pada bekas seksio sesarea harus tersedia tim yang siap untuk melakukan seksio
sesarea emergensi dalam waktu 20 sampai 30 menit untuk antisipasi apabila terjadi fetal distress
atau ruptura uteri
(Jukelevics N, 2000)


C. Faktor yang berpengaruh
Seorang ibu hamil dengan bekas seksio sesarea akan dilakukan seksio sesarea kembali
atau dengan persalinan pervaginam tergantung apakah syarat persalinan pervaginam terpenuhi
atau tidak. Setelah mengetahui ini dokter mendiskusikan dengan pasien tentang pilihan serta
resiko masing-masingnya. Tentu saja hak pasien untuk meminta jenis persalinan mana yang
terbaik untuk dia dan bayinya.
( Golberg B, MD, 2000 )

Faktor-faktor yang berpengaruh dalam menentukan persalinan pada pasien bekas seksio
sesarea telah diteliti selama bertahun-tahun.
Ada banyak faktor yang dihubungkan dengan tingkat keberhasilan persalinan pervaginam pada
bekas seksio
(Caughey AB, Mann S, 2001).

1. Teknik operasi sebelumnya.
Pasien bekas seksio sesarea dengan insisi segmen bawah rahim transversal merupakan
salah satu syarat dalam melakukan persalinan pervaginam, dimana pasien dengan tipe insisi ini
mempunyai resiko ruptur yang lebih rendah dari pada tipe insisi lainnya. Bekas seksio sesarae
klasik, insisi T pada uterus dan komplikasi yang terjadi pada seksio sesarea yang lalu misalnya
laserasi serviks yang luas merupakan kontraindikasi melakukan persalinan pervaginam.
(Toth PP,
Jothivijayani, 1996, Cunningham FG, 2001)

2. Jumlah seksio sesarea sebelumnya
Flamm tidak melakukan persalinan pervaginam pada semua bekas seksio sesarea
korporal maupun pada kasus yang pernah seksio sesarea dua kali berurutan atau lebih, sebab
pada kasus tersebut diatas seksio sesarea elektif adalah lebih baik dibandingkan persalinan
pervaginam
(Flamm BL, 1985)

Resiko ruptur uteri meningkat dengan meningkatnya jumlah seksio sesarea sebelumnya.
Pasien dengan seksio sesarea lebih dari satu kali mempunyai resiko yang lebih tinggi untuk
terjadinya ruptura uteri. Ruptura uteri pada bekas seksio sesarea 2 kali adalah sebesar 1.8 3.7
%. Caughey dan kawan-kawan mendapatkan bahwa pasien dengan bekas seksio sesarea 2 kali
mempunyai resiko ruptura uteri lima kali lebih besar dari bekas seksio sesarea satu kali.
( Caughey
AB, 1999, Cunningham FG, 2001)
Spaan dkk mendapatkan bahwa riwayat seksio sesarea yang lebih satu
kali mempunyai resiko untuk seksio sesarea ulang lebih tinggi.
(Spaan WA et al, 1997)

17


Jamelle (1996) menyatakan diktum sekali seksio sesarea selalu seksio sesarea tidaklah
selalu benar, tetapi beliau setuju dengan setelah dua kali seksio sesarea selalu seksio sesarea pada
kehamilan berikutnya , dimana diyakini bahwa komplikasi pada ibu dan anak lebih tinggi.
(Jamelle
RN, 1996)

Farmakides dkk (1987) melaporkan 77 % dari pasien yang pernah seksio sesarea dua kali
atau lebih yang diperbolehkan persalinan pervaginam dan berhasil dengan luaran bayi yang
baik. ACOG 1999 telah memutuskan bahwa pasien dengan bekas seksio dua kali boleh
menjalani persalinan pervaginam dengan pengawasan yang ketat
(Farmakides G, et al, 1987, Cunningham FG,
2001)

Miller 1994 melaporkan bahwa insiden ruptura uteri terjadi 2 kali lebih sering pada
persalinan ibu dengan riwayat seksio sesarea 2 kali atau lebih. Keberhasilan persalinan
pervaginam bekas seksio sesarea 1 kali adalah 83 % dan 75 % keberhasilan persalinan
pervaginam bekas seksio sesarea 2 kali atau lebih.,
(Miller, et al, 1996)

3. Penyembuhan luka pada seksio sesarea sebelumnya
Pada seksio sesarea insisi kulit pada dinding abdomen biasanya melalui "potongan
bikini" kadang-kadang pemotongan atas bawah yang disebut insisi kulit vertikal. Kemudian
pemotongan dilanjutkan sampai ke uters. Daerah uterus yang ditutupi oleh kandung kencing
disebut segmen bawah rahim, hampir 90 % insisi uterus dilakukan di tempat ini berupa sayatan
kesamping (seperti potongan bikini). Cara pemotongan uterus seperti ini disebut " Low
Transverse Cesarean Section ". Insisi uterus ini ditutup/jahit akan sembuh dalam 2 6 hari.
Insisi uterus dapat juga dibuat dengan potongan vertikal yang dikenal dengan seksio sesarea
klasik, irisan ini dilakukan pada otot uterus. Luka pada uterus dengan cara ini mungkin tidak
dapat pulih seperti semula dan dapat terbuka lagi sepanjang kehamilan atau persalinan
berikutnya.
(Hill AD, 2002}

Depp R menganjurkan persalinan pervaginam pada bekas seksio sesarea, terkecuali ada
tanda-tanda ruptura uteri mengancam, parut uterus yang sembuh persekundum pada seksio
sesarea sebelumnya atau jika adanya penyulit obstetrik lain ditemui.
(Depp R, 1996)

Rosenberg (1996) menjelaskan bahwa dengan pemeriksaan Ultra sonografi USG trans
abdominal pada kehamilan 37 minggu dapat diketahui ketebalan segmen bawah rahim .
Ketebalan SBR 4,5 mm pada usia kehamilan 37 minggu adalah petanda parut yang sembuh
sempurna. Parut yang tidak sembuh sempurna didapat jika ketebalan SBR < 3,5 mm. Oleh sebab
itu pemeriksaan USG pada kehamilan 37 minggu dapat sebagai alat skrining dalam memilih cara
persalinan bekas seksio sesarea.
(Rozenberg P, et al, 1996)

Willams (dikutip dari Cunningham) menyatakan bahwa penyembuhan luka seksio
sesarea adalah suatu generasi dari fibromuskuler dan bukan pembentukan jaringan sikatrik.



18


Dasar dari keyakinan ini adalah dari hasil pemeriksaan histologi dari jaringan di daerah bekas
sayatan seksio sesarea dan dari 2 tahap observasi yang pada prinsipnya :
(Cunningham FA, 1993)

1. Tidak tampaknya atau hampir tidak tampak adanya jaringan sikatrik pada uterus pada
waktu dilakukan seksio sesarea ulangan
2. Pada uterus yang diangkat, sering tidak kelihatan garis sikatrik atau hanya ditemukan
suatu garis tipis pada permukaan luar dan dalam uterus tanpa ditemukannya sikatrik
diantaranya.

Mason (dikutip dari Schmitz 1949) menyatakan bahwa kekuatan sikatrik pada uterus
pada penyembuhan luka yang baik adalah lebih kuat dari miometrium itu sendiri. Hal ini telah
dibuktikannya dengan memberikan regangan yang ditingkatkan dengan penambahan beban pada
uterus bekas seksio sesarea (hewan percobaan). Ternyata pada regangan maksimal terjadi ruptura
bukan pada jaringan sikatriknya tetapi pada jaringan miometrium dikedua sisi sikatrik.
Dari laporan-laporan klinis pada uterus gravid bekas seksio sesarea yang mengalami
ruptura selalu terjadi pada jaringan otot miometrium sedangkan sikatriknya utuh. Yang mana hal
ini menandakan bahwa jaringan sikatrik yang terbentuk relatif lebih kuat dari jaringan
miometrium itu sendiri.
(Schmitz 1949)

Dua hal yang utama penyebab dari gangguan pembentukan jaringan sehingga
menyebabkan lemahnya jaringan parut tersebut Adalah :
1. Infeksi, bila terjadi infeksi akan mengganggu proses penyembuhan luka.
2. Kesalahan teknik operasi (technical errors) seperti tidak tepatnya pertemuan kedua
sisi luka, jahitan luka yang terlalu kencang, spasing jahitan yang tidak beraturan,
penyimpulan yang tidak tepat, dan lain-lain.
Cooke (dikutip daro Schmitz 1949) menyatakan jahitan luka yang terlalu kencang dapat
menyebabkan nekrosis jaringan sehingga merupakan penyebab timbulnya gangguan kekuatan
sikatrik, hal ini lebih dominan dari pada infeksi ataupun technical error sebagai penyebab
lemahnya sikatrik.

Alasan melakukan seksio sesarea ulangan secara rutin sebagai tindakan profilaksis
terhadap kemungkinan terjadinya ruptura uteri tidak benar lagi. Pengetahuan tentang
penyembuhan luka operasi, kekuatan jaringan sikatrik pada penyembuhan luka operasi yang baik
dan pengetahuan tentang penyebab-penyebab yang dapat mengurangi kekuatan jaringan sikatrik
pada bekas seksio sesarea, menjadi panduan apakah persalinan pervaginam pada bekas seksio
sesarea dapat dilaksanakan atau tidak.
(Whitesside 1983, Flamm 1985, Ngu 1985)

Pada sikatrik uterus yang intak tidak mempengaruhi aktivitas selama kontraksi uterus.
Aktivitas uterus pada multipara dengan bekas seksio sesarea sama dengan multipara tanpa seksio
sesarea yang menjalani persalinan pervaginam
(Chua S, Arulkumaran S, 1997)

4. Indikasi operasi pada seksio sesarea yang lalu.
Indikasi seksio sesarea sebelumnya akan mempengaruhi keberhasilan persalinan
pervaginam pada bekas seksio sesarea , CPD memberikan keberhasilan persalinan pervaginam
19


sebesar 60 65 %. Fetal distress memberikan keberhasilan sebesar 69 73 %
(Caughey AB, Mann S,
2001)

Keberhasilan persalinan pervaginam pada pasien bekas seksio sesarea ditentukan juga
oleh keadaan dilatasi servik pada waktu dilakukan seksio sesarea yang lalu. Persalinan
pervaginam berhasil 67 % apabila seksio sesarea yang lalu dilakukan pada saat pembukaan
serviks kecil dari 5 cm, dan 73 % pada pembukaan 6 sampai 9 cm. Keberhasilan persalinan
pervaginam menurun sampai 13 % apabila seksio sesarea yang lalu dilakukan pada keadaan
distosia pada kala II.
(Cunningham FG, 2001)

Troyer 1992 pada penelitiannya mendapatkan keberhasilan penanganan persalinan
pervaginam bekas seksio sesarea bisa dihubungkan dengan indikasi seksio sesarea yang lalu
seperti pada tabel dibawah ini :
(Troyer, 1992)







Tabel 1. Hubungan indikasi seksio sesarea lalu dengan keberhasilan
penanganan persalinan pervaginam bekas seksio sesarea.
Indikasi seksio yang lalu Keberhasilan VBAC
1. Letak sungsang
2. Fetal distress
3. Solusio plasenta
4. Plasenta previa
5. Gagal induksi
6. Disfungsi persalinan
80.5
80.7
100
100
79.6
63.4

5. Usia ibu
Usia ibu yang aman untuk melahirkan adalah sekitar 20 tahun sampai 34 tahun. Usia
melahirkan dibawah 20 tahun dan diatas 35 tahun digolongkan resiko tinggi. Dari penelitian
didapatkan wanita yang berumur lebih dari 35 tahun mempunyai angka seksio sesarea yang lebih
tinggi. Wanita yang berumur lebih dari 40 tahun dengan bekas seksio sesarea mempunyai resiko
kegagalan untuk persalinan pervaginam lebih besar tiga kali dari pada wanita yang berumur
kecil dari 40 tahun.
(Caughey AB, Mann S, 2001)

Weinstein dkk mendapatkan pada penelitian mereka bahwa faktor umur tidak bermakna
20


secara statistik dalam mempengaruhi keberhasilan persalinan pervaginam pada bekas seksio
sesarea.
(Weinstein D, et al, 1996)

6. Usia kehamilan saat seksio sesarea sebelumnya
Pada usia kehamilan < 37 minggu dan belum inpartu misalnya pada plasenta previa
dimana segmen bawah rahim belum terbentuk sempurna kemungkinan insisi uterus tidak pada
segmen bawah rahim dan dapat mengenai bagian korpus uteri yang mana keadaannya sama
dengan insisi pada seksio sesarea klasik
(Salzmann B, 1994)

7. Riwayat persalinan pervaginam
Riwayat persalinan pervaginam baik sebelum ataupun sesudah seksio sesarea
mempengaruhi prognosis keberhasilan persalinan pervaginam pada bekas seksio
sesarea.
(Cunningham FG, 2001)


Pasien dengan bekas seksio sesarea yang pernah menjalani persalinan pervaginam
memiliki angka keberhasilan persalinan pervaginam yang lebih tinggi dibandingkan dengan
pasien tanpa persalinan pervaginam .
( Caughey AB, Mann S, 2001)
Pada bekas seksio sesarea yang
sesudahnya pernah berhasil dengan persalinan pervaginam, makin berkurang kemungkinan
ruptura uteri pada kehamilan dan persalinan yang akan datang. Walaupun demikian ancaman
ruptura uteri tetap ada pada masa kehamilan maupun persalinan, oleh sebab itu pada setiap kasus
bekas seksio sesarea harus juga diperhitungkan ruptura uteri pada kehamilan trimester ketiga
terutama saat menjalani persalinan pervaginam.
(Benedetti TJ, 1982)

8. Keadaan serviks pada saat inpartu
Flamm mengatakan bahwa penipisan serviks serta dilatasi serviks memperbesar
keberhasilan persalinan pervaginam bekas seksio sesarea.
(Flamm BL, 1997)

Guleria dan Dhall 1997 menyatakan bahwa laju dilatasi seviks mempengaruhi
keberhasilan penanganan persalinan pervaginam bekas seksio sesarea. Dari 100 pasien bekas
seksio sesarea segmen bawah rahim di dapat 84 % berhasil persalinan pervaginam sedangkan
sisanya adalah seksio sesarea darurat. Gambaran laju dilatasi serviks pada bekas seksio sesarea
yang berhasil pervaginam pada fase laten rata-rata 0.88 cm/jam. Fase aktif 1.25 cm/jam.
Sedangkan laju dilatasi serviks pada bekas seksio sesarea yang gagal pervaginam pada fase late
rata-rata 0.44 cm / jam dan fase aktif adalah 0.42 cm /jam.
(Guleria K, 1997)

Induksi persalinan dengan misoprostol akan meningkatkan resiko ruptura uteri pada
wanita dengan bekas seksio sesarea.
(Plaut MM, et al, 1999)
Dijumpai adanya 1 kasus ruptura uteri
bekas seksio sesaraea segmen bawah rahim transversal selama dilakukan pematangan serviks
dengan transvaginal misoprostol sebelum tindakan induksi persalinan.
(Sciscione AC, 1998)

9. Keadaan selaput ketuban
Carrol 1990 melaporkan pasien dengan ketuban pecah dini (KPD) pada usia kehamilan
diatas 37 minggu dengan bekas seksio sesarea (56 kasus) proses persalinannya dapat pervaginam
dengan menunggu terjadinya inpartu spontan dan didapat angka keberhasilan yang tinggi (91 % )
dengan menghindari pemberian induksi persalinan dengan oxytosin , dengan rata-rata lama
waktu antara terjadinya KPD sampai terjadinya persalinan adalah 42,6 jam dengan keadaan ibu
dan bayi baik.
(Carrol SG, 1990)

21



E. Kriteria Seleksi
American College of Obstetricians and Gynecologists tahun 1999 memberikan
rekomendasi untuk menyeleksi pasien yang direncanakan untuk persalinan pervaginam pada
bekas seksio sesarea.
Kriteria seleksinya adalah sebagai berikut:
( Cunningham FG, 2001)

- Riwayat 1 atau 2 kali seksio sesarea dengan insisi Segmen Bawah Rahim.
- Secara klinis panggul adekuat atau imbang fetopelvik baik
- Tak ada bekas ruptur uteri atau bekas operasi lain pada uterus
- Tersedianya tenaga yang mampu untuk melaksanakan monitoring, persalinan dan
seksio sesarea emergensi.
- Sarana dan personil anastesi siap untuk menangani seksio sesarea darurat
Kriteria yang masih kontroversi
(Phelan JP et al 1993, Depp R, 1996, Cunningham FG, 2001)

- Parut uterus yang tidak diketahui
- Parut uterus pada Segmen Bawah Rahim vertikal
- Kehamilan kembar
- Letak sungsang
- Kehamilan lewat waktu
- Taksiran berat janin lebih dari 4000 gram

F. Kontra Indikasi
Kontra indikasi mutlak melakukan persalinan pervaginam pada bekas seksio sesarea:
(Depp R, 1996)

- Bekas seksio sesarea klasik
- Bekas seksio sesarea dengan insisi T
- Bekas ruptur uteri
- Bekas komplikasi operasi seksio sesarea dengan laserasi serviks yang luas
- Bekas sayatan uterus lainnya di fundus uteri. Misalnya miomektomi
- Cefalo Pelviks Disporposi yang jelas.
- Pasien menolak persalinan pervaginam
- Panggul sempit
- Ada komplikasi medis dan obstetrik yang merupakan kontra indikasi persalinan
pervaginam.

G. Induksi
Zelop CM meneliti induksi persalinan dengan oksitosin pada pasien bekas seksio sesarea
satu kali. Disimpulkan bahwa induksi persalinan dengan oksitosin meningkatkan kejadian ruptur
uteri pada wanita hamil dengan bekas seksio sesarea satu kali dibandingkan dengan partus
spontan tanpa induksi. Secara statistik tidak didapatkan peningkatan yang bermakna kejadian
ruptur uteri pada pasien yang didrip akselerasi dengan oksitosin. Namun pemakaian oksitosin
untuk drip akselerasi pada pasien bekas seksio sesarea harus diawasi secara ketat.
(Zelop CM, 1999)

Abdullah F mendapatkan tingkat keberhasilan pemberian oksitosin pada persalinan bekas
22


seksio sesarea cukup tinggi yaitu 70% pada induksi persalinan dan 100% pada akselerasi
persalinan.
(Abdullah F, 1998)

Plaut MM melaporkan kejadian ruptur uteri pada pasien yang menjalani persalinan
percobaan pervaginam setelah seksio sesarea yang diinduksi dengan misoprostol. Ruptur uteri
terjadi pada 5 dari 89 pasien dengan bekas seksio sesarea yang diinduksi dengan misoprostol.
Kejadian ruptur pada kasus ini tinggi dan bermakna secara statistik sehingga disimpulkan induksi
persalinan dengan misoprostol meningkatkan resiko ruptur uteri pada pasien bekas seksio
sesarea.
(Plaut MM et al, 1999)


H. Resiko terhadap Ibu
Resiko terhadap ibu yang melakukan persalinan pervaginam dibandingkan dengan seksio
sesarea ulangan elektif pada bekas seksio sesarea.
(Kirk EP, 1990, Golberg B, 2000)

- Insiden demam lebih kecil secara bermakna pada persalinan pervaginam yang
berhasil dibanding dengan seksio sesarea ulangan elektif
- Pada persalinan pervaginam yang gagal yang dilanjutkan dengan seksio sesarea
insiden demam lebih tinggi
- Tidak banyak perbedaan insiden dehisensi uterus pada persalinan pervaginam
dibanding dengan seksio sesarea elektif.
- Dehisensi atau ruptur uteri setelah gagal persalinan pervaginam adalah 2.8 kali dari
seksio sesarea elektif.
- Mortalitas ibu pada seksio sesarea ulangan elektif dan persalinan pervaginam sangat
rendah
- Kelompok persalinan pervaginam mempunyai rawat inap yang lebih singkat,
penurunan insiden transfusi darah pada paska persalinan dan penurunan insiden demam
paska persalinan dibanding dengan seksio sesarea elektif

I. Resiko terhadap Anak
Resiko terhadap perinatal dan neonatal dalam melakukan persalinan pervaginam pada
bekas seksio sesarea
Rosen melaporkan angka kematian perinatal 1.4 % dari hasil penelitian terhadap lebih
dari 4.500 persalinan pervaginam. Rosen juga melaporkan resiko kematian perinatal pada
persalinan percobaan adalah 2.1 kali lebih besar dibanding seksio sesarea elektif (p<0.001).
namun jika berat badan janin < 750 gram dan kelainan kongenital berat tidak diperhitungkan
maka angka kematian perinatal dari persalinan pervaginam tidak berbeda bermakna dari seksio
sesarea ulangan elektif.
(Rosen MG,1991)

Flamm (1994) melaporkan angka kematian perinatal adalah 7 per 1.000 kelahiran hidup
pada persalinan pervaginam, angka ini tidak berbeda bermakna dari angka kematian perinatal
dari Rumah Sakit yang ditelitinya (10 per 1.000 kelahiran hidup.
(Flamm BL, 1994)

Cowan (1994) melaporkan sebagian besar 463 dari 478 (97 %) dari bayi yang lahir
pervaginam mempunyai Apgar skor pasda 5 menit pertama adalah 8 atau lebih.
(Cowan, 1994)
.
Mahon (1996) melaporkan bahwa apgar skor bayi yang lahir tidak berbeda bermakna pada
persalinan pervaginam dibanding seksio sesarea ulangan elektif.
(Mahon MJ, 1996)
. Hook (1997)
23


melaporkan morbiditas bayi yang lahir dengan seksio sesarea ulangan setelah gagal persalinan
pervaginam lebih tinggi dibandingkan dengan yang berhasil persalinan pervaginam. Dan
morbiditas bayi yang berhasil persalinan pervaginam tidak berbeda bermakna dengan bayi yang
lahir normal
(Hook B, 1997)
.
J. Komplikasi
Komplikasi paling berat yang dapat terjadi dalam melakukan persalinan pervaginam adalah
ruptura uteri. Ruptur jaringan parut bekas seksio sesarea sering tersembunyi dan tidak
menimbulkan gejala yang khas.
(Jones OR et al, 1991)
Dilaporkan bahwa kejadian ruptur uteri pada
bekas seksio sesarea insisi Segmen Bawah Rahim lebih kecil dari 1 % (0,2 0,8 % ). Kejadian
ruptura uteri pada persalinan pervaginam dengan riwayat insisi seksio sesarea korporal
dilaporkan oleh Scott dan American College of Obstetricans and Gynekologists adalah sebesar 4
9 %.
(Scott, JR, 1997, ACOG, 1998)
Farmer melaporkan kejadian ruptur uteri selama partus percobaan
pada bekas seksio sesarea sebanyak 0,8% dan dehisensi 0,7% .
(Farmer RM, 1991)

Apabila terjadi ruptur uteri maka janin, tali pusat, plasenta atau bayi akan keluar dari
robekan rahim dan masuk ke rongga abdomen. Hal ini akan menyebabkan perdarahan pada ibu,
gawat janin dan kematian janin serta ibu. Kadang-kadang harus dilakukan histerektomi
emergensi. Kasus ruptur uteri ini lebih sering terjadi pada seksio sesarea klasik dibandingkan
dengan seksio sesarea pada segmen bawah rahim. Ruptur uteri pada seksio sesarea klasik terjadi
5-12 % sedangkan pada seksio sesarea pada segmen bawah rahim 0,5-1 %
(Hill DA, 2002)

Tanda yang sering dijumpai pada ruptura uteri adalah denyut jantung janin tak normal
dengan deselerasi variabel yang lambat laun menjadi deselerasi lambat, bradiakardia, dan denyut
janin tak terdeteksi. Gejala klinis tambahan adalah perdarahan pervaginam, nyeri abdomen,
presentasi janin berubah dan terjadi hipovolemik pada ibu.
(Manihan CA,1998)

Tanda-tanda ruptura uteri adalah sebagai berikut :
(Caughey AB, et al, 2001)

Nyeri akut abdomen
Sensasi popping ( seperti akan pecah )
Teraba bagian-bagian janin diluar uterus pada pemeriksaan Leopold
Deselerasi dan bradikardi pada denyut jantung bayi
Presenting parutnya tinggi pada pemeriksaan pervaginam
Perdarahan pervaginam

Pada wanita dengan bekas seksio sesarea klasik sebaiknya tidak dilakukan persalinan
pervaginam karena resiko ruptur 2-10 kali dan kematian maternal dan perinatal 5-10 kali lebih
tinggi dibandingkan dengan seksio sesarea pada segmen bawah rahim.
(Chua S,Arunkumaran S,1997)


K. Monitoring
Ada beberapa alasan mengapa seseorang wanita seharusnya dibantu dengan persalinan
pervaginam. Hal ini disebabkan karena komplikasi akibat seksio sesarea lebih tinggi. Pada
seksio sesarea terdapat kecendrungan kehilangan darah yang banyak, peningkatan kejadian
transfusi dan infeksi, akan menambah lama rawatan masa nifas di Rumah Sakit. Juga akan
memperlama perawatan di rumah dibandingkan persalinan pervaginam. Sebagai tambahan biaya
Rumah Sakit akan dua kali lebih mahal.
( Golberg B, MD, 2000 )

24


Walaupun angka kejadian ruptur uteri pada persalinan pervaginam setelah seksio sesarea
adalah rendah, tapi hal ini dapat menyebabkan kematian pada janin dan ibu. Untuk antisipasi
perlu dilakukan monitoring pada persalinan ini.
.(Caughey AB, 1999, Nicette J, 2000)

Pasien dengan bekas seksio sesarea membutuhkan manajemen khusus pada waktu
antenatal maupun pada waktu persalinan. Jika persalinan diawasi dengan ketat melalui monitor
kardiotokografi kontinu; denyut jantung janin dan tekanan intra uterin dapat membantu untuk
mengidentifikasi ruptur uteri lebih dini sehingga respon tenaga medis bisa cepat maka ibu dan
bayi bisa diselamatkan apabila terjadi ruptur uteri
.(Farmer RM at al, 1991, Caughey AB, 1999, Nicette J, 2000)

L. Sistem Skoring
Untuk meramalkan keberhasilan penanganan persalinan pervaginam bekas seksio
sesarea, beberapa peneliti telah membuat sistem skoring. Flamm dan Geiger menentukan
panduan dalam penanganan persalinan bekas seksio sesarea dalam bentuk sistem skoring .
Weinstein dkk juga telah membuat suatu sistem skoring untuk pasien bekas seksio sesarea
(Weinstein D, 1996, Flamm BL, 1997)


Adapun skoring menurut Flamm dan Geiger yang ditentukan untuk memprediksi
persalinan pada wanita dengan bekas seksio sesarea adalah seperti tertera pada table dibawah ini:

No Karakteristik Skor
1
2




3
4




5
Usia < 40 tahun
Riwayat persalinan pervaginam
- sebelum dan sesudah seksio sesarea
- persalinan pervaginam sesudah seksio sesarea
- persalinan pervaginam sebelum seksio sesarea
- tidak ada
Alasan lain seksio sesarea terdahulu
Pendataran dan penipisan serviks saat tiba di Rumah Sakit dalam
keadaan inpartu:
- 75 %
- 25 75 %
- < 25 %
Dilatasi serviks 4 cm
2

4
2
1
0
1


2
1
0
1

Dari hasil penelitian Flamm dan Geiger terhadap skor development group diperoleh hasil
seperti table dibawah ini:

Skor Angka Keberhasilan (%)
0 2
3
4
42-49
59-60
64-67
25


5
6
7
8 10
77-79
88-89
93
95-99
Total 74-75

Weinstein dkk juga telah membuat suatu sistem skoring yang bertujuan untuk
memprediksi keberhasilan persalinan pervaginam pada bekas seksio sesarea, adapun sistem
skoring yang digunakan adalah

FAKTOR TIDAK YA

Bishop Score 4
Riwayat persalinan pervaginam sebelum seksio sesarea
Indikasi seksio sesarea yang lalu
Malpresentasi, Preeklampsi/Eklampsi, Kembar
HAP, PRM, Persalinan Prematur
Fetal Distres, CPD, Prolapsus tali pusat
Makrosemia, IUGR

0
0

0
0
0
0

4
2

6
5
4
3

Angka keberhasilan persalinan pervaginam pada bekas seksio sesarea pada sistem
skoring menurut Weinstein dkk adalah seperti di tabel berikut:

Nilai scoring Keberhasilan
4
6
8
10
12
58 %
67 %
78 %
85 %
88 %







BAB IV
26


DISKUSI

Telah dipresentasikan kasus seorang pasien wanita, berusia 33 tahun, masuk RS. M.
Jamil tanggal 4 November 2008 jam 15.00 wib dengan diagnosa G
2
P
1
A
0
H
1
gravid aterm 39 40
mg + Bekas SC + PRM, anak hidup tunggal intra uterin letak kepala H
I-II
. Kemudian
direncanakan melakukan drip induksi. Setelah dilakukan induksi persalinan pada kolf kedua,
akhirnya pasien melahirkan bayi perempuan () secara spontan dengan BB : 3576 gr, PB : 50
cm, dan A/S : 8/9. Setelah dirawat 2 hari di kamar rawat kebidanan, pasien pulang dalam
keadaan baik.
Ditinjau dari segi diagnosis dan penatalaksanaan pada kasus ini dapat dikemukakan
beberapa permasalahan yaitu : apakah diagnosis pasien saat masuk RS sudah tepat? Apakah
penatalaksanaan pasien ini sudah tepat?
Diagnosis pada pasien ini pada waktu masuk RS adalah G
2
P
1
A
0
H
1
gravid aterm 39 40
mg + Bekas SC + PRM, anak hidup tunggal intra uterin letak kepala H
I-II
.dari anamnesa
didapatkan keluhan keluar air air yang banyak dari kemaluan sejak 7 jam yang lalu, membasahi
1 helai kain sarung, bau amis, warna jernih, tidak disertai tanda tanda inpartu, tidak haid sejak
9 bulan yang lalu dengan HPHT yang jelas, kemudian riwayat SC pada anak pertama. Dari
pemeriksaan fisik pada abdomen didapatkan tampak membuncit sesuai usia kehamilan aterm,
FUT 3 jari bpx dengan TFU 34 cm dan TBA 3255 gr, letak kepala dengan punggung di sebelah
kiri dan BJA 150x/menit. Kemudian dari pemeriksaan genitalia didapatkan tampak cairan di
fornix posterior dan mengalir dari canalis servikalis dengan Lakmus test (+), dari VT didapatkan
pembukaan 1 jari, portio tebal 1cm, medial, lunak, ketuban (-) sisa jernih, teraba kepala H
I-II .
Dapat disimpulkan saat masuk pasien telah mengalami pecah ketuban atau biasa disebut PRM (
Premature Rupture Of The Membranes ). Dimana sampai saat ini belum ada kesepakatan tentang
definisi Premature Rupture Of The Membranes, demikian juga dengan terjemahannya. Di RS
Soetomo Surabaya dan RS Cipto Mangunkusumo dipakai istilah ketuban pecah dini, di RS
Hasan Sadikin Bandung dipakai istilah ketuban pecah sebelum waktunya, sedangkan di RS. Dr.
M. Djamil Padang dipakai istilah PRM.

Definisi yang dikemukakan saat ini adalah :
1. Di RS Cipto Mangunkusumo Jakarta memakai batasan pembukaan 5 cm atau kurang
untuk ketuban pecah sebelum waktunya (Sudarmadi).
2. Di RS Soetomo Surabaya mendefinisikan ketuban pecah sebelum waktunya bila ketuban
pecah setiap saat 1 2 jam atau lebih sebelum persalinan dimulai (Reksonotoprodjo).
3. Di RS Hasan Sadikin Bandung memakai definisi ketuban pecah sebelum waktunya bila
ketuban pecah setiap saat sebelum pembukaan 3 4 cm (Ahmad).
4. Di RS M Jamil Padang mendefenisikan ketuban pecah dini bila ketuban pecah sebelum
27


adanya tanda tanda inpartu
Sedang definisi Ketuban Pecah Dini menurut tinjauan kepustakaan luar antara lain :
1. Dari Cuningham, 1997 : Pecahnya ketuban sebelum onset persalinan baik pada
kehamilan aterm, maupun aterm
2. Dari Dutta DC, 1998 : Pecahnya membran amnion secara spontan setiap saat antara 28
minggu usia kehamilan, tetapi sebelum onset persalinan
3. Dari Gabbe S et al, 1996 : Keluarnya cairan amnion paling kurang 1 jam sebelum onset
persalinan disetiap umur kehamilaan.
Pada kasus ini penatalaksanaan yang dipilih adalah induksi persalinan yang sesuai
dengan penatalaksanaan pada kasus ketuban pecah dini lebih dari 6 jam. Dimana pada usia
kehamilan lebih dari 37 minggu (aterm) dengan PRM dilakukan terminasi kehamilan. Di RS. Dr.
M. Djamil Padang dilakukan induksi persalinan apabila setelah 6 jam ketuban pecah tidak timbul
tanda inpartu.
Induksi suatu persalinan ialah suatu tindakan terhadap ibu hamil yang belum inpartu, baik
secara operatif maupun secara medisinal, untuk merangsang timbulnya kontraksi rahim sehingga
terjadi persalinan. Induksi persalinan berbeda dengan akselerasi persalinan, dimana pada
akselerasi persalinan tindakan tindakan tersebut dikerjakan pada wanita hamil yang sudah
inpartu.
Indikasi induksi persalinan pada janin
1. Kehamilan lewat waktu.
2. Ketuban pecah dini.
3. Janin mati
Kontra indikasi induksi persalinan:
1. Malposisi dan malpresentasi
2. Insufisiensi plasenta
3. Disproporsi sefalopelvik
4. Cacat rahim
5. Grande multipara, lebih dari 5
6. Plasenta previa totalis
Namun masalahnya disini, pasien dengan riwayat SC pada persalinan sebelumnya sehingga
mempunyai resiko terhadap induksi persalinan dan persalinan pervaginam. Zelop CM meneliti
28


induksi persalinan dengan oksitosin pada pasien bekas seksio sesarea dan menyimpulkan bahwa
induksi persalinan dengan oksitosin meningkatkan kejadian ruptur uteri pada wanita hamil
dengan bekas seksio sesarea satu kali dibandingkan dengan partus spontan tanpa induksi. Secara
statistik tidak didapatkan peningkatan yang bermakna kejadian ruptur uteri pada pasien yang
didrip akselerasi dengan oksitosin. Namun pemakaian oksitosin untuk drip akselerasi pada pasien
bekas seksio sesarea harus diawasi secara ketat. Abdullah F mendapatkan tingkat keberhasilan
pemberian oksitosin pada persalinan bekas seksio sesarea cukup tinggi yaitu 70% pada induksi
persalinan dan 100% pada akselerasi persalinan. Plaut MM melaporkan kejadian ruptur uteri
pada pasien yang menjalani persalinan percobaan pervaginam setelah seksio sesarea yang
diinduksi dengan misoprostol. Ruptur uteri terjadi pada 5 dari 89 pasien dengan bekas seksio
sesarea yang diinduksi dengan misoprostol. Kejadian ruptur pada kasus ini tinggi dan bermakna
secara statistik sehingga disimpulkan induksi persalinan dengan misoprostol meningkatkan
resiko ruptur uteri pada pasien bekas seksio sesarea.
Sedangkan pilihan persalinan pervaginam pada pasien ini telah memenuhi kriteria seleksi
pada pasien bekas SC. Menurut Cunningham FG, 2001 kriteria seleksinya adalah sebagai
berikut:


- Riwayat 1 atau 2 kali seksio sesarea dengan insisi Segmen Bawah Rahim..
- Secara klinis panggul adekuat atau imbang fetopelvik baik
- Tak ada bekas ruptur uteri atau bekas operasi lain pada uterus
- Tersedianya tenaga yang mampu untuk melaksanakan monitoring, persalinan dan
seksio sesarea emergensi.
- Sarana dan personil anastesi siap untuk menangani seksio sesarea darurat
Komplikasi paling berat yang dapat terjadi dalam melakukan persalinan pervaginam adalah
ruptura uteri. Ruptur jaringan parut bekas seksio sesarea sering tersembunyi dan tidak
menimbulkan gejala yang khas.


BAB V
KESIMPULAN

Diagnosis pada pasien ini sudah tepat namun penatalaksanaan pada pasien ini masih ada
kelemahannya.

DAFTAR PUSTAKA


29


Abdullah F, 1998. Tingkat Keberhasilan Induksi dan Akselerasi Persalinan dengan Oksitosin
pada Persalinan Bekas Seksio Sesarea Satu Kali. Tesis untuk Brevet Spesialis Obstetri dan
Ginekologi di FKUA Padang 1998.

Caughey AB , Mann S. Vaginal Birth After Cesarean, Medicine Journal 2001; 2(9) In:
http//www.emedicine.com/med/topic3434.htm

Chua S, Arulkumaran S. Trial of scar. In: Australia , NZ Journal Obstetrics and Gynecology.
1997; 37; 6 11.

Clarke SC, Taffel S, Changes in Cesarean Delivery in the United States 1988 and 1993. In:
Birth 1995; 22: 63.

Cunningham FG, Gant NF, Leveno KJ. Cesarean Section and Postpartum Hysterectomy. In :
Williams Obstetrics. 21
st
Ed.. The Mc Graw-Hill Companies. New York : 2001 : 537
63.

Cunningham MD. Cesarean Section. In: Williams Obstetrics, 22
nd
Ed. Prentice Hall Int. USA
. 2001..

Depp R. Casarean Delivery. In: Obstetrics Normal & Problem Pregnancies. 3
rd
Ed. Churchill
Livingstone. New York : 1996: 561 642.

Flamm BL, Geiger AM, Vaginal Birth After Cesarean: An Admission Skoring System. In:
Journal Obstetrics and Gynecology. 1997; 90(6): 907 1010

Guleria K Dhall GI, Dhall K. Pattern of Cervical Dilatation in Previous Segment Cesarean
Section Patients. In: Indian Journal Medicine Association. 1997; 95: 131 4.

Hill DA. Issues and Procedures in Women's Health Vaginal Birth After Cesarean. Obgyn. net
Publications 2002.. In: http://www.obgyn.net/women/article/VBACdahhtm.

Husodo L, Pembedahan dengan Laparatomi. Dalam Buku Ilmu Kebidanan Yayasan Bina
Pustaka Sarwono Prawirohardjo. Jakarta. 1999: 863 75.

Jamelle RN. Outcome of Unplanned Vaginal Deliveries After Two Previous Cesarean
Section. In: Journal Obstetrics and Gynecology. 1996; 22: 431 6

30


Jukelevics N, Evaluating the Risk of Uterine Rupture. ICCE. 2000. In:
http://www.abcbirth.com/hVBAC.htmlLavin JP, Stephen RJ, Miodovnik M, et al.

Kirk EP, Doyle AK, Leight J, et al. Vaginal Birth After Cesarean of Repeat Cesarean
Section. In: American Journal Obstetrics and Gynecology 1990; 162: 1398 405.
Golberg B. Vaginal Birth After Cesarean. Article 2000. In:
http://www.obgyn.net/displayarticle.asp?page=/pb/articles/vbac.

Miller DA, Diaz FG, Paul RH. Vaginal Birth After Cesarean : A 10-Year Experience. In:
Journal Obstetrics and Gynecology. 1994; 84(2): 255 9.

O'Grandy JP, Veronikis DK, Chervenak FA, et al. Cesarean Delivery. In: Operative
Obstetrics. Williams & Wilkins A Waverly Company. Blatimore , USA . 1995: 239 61.

Plaut MM, Schwartz ML, Lubarsky SL. Uterine Rupture Associated with Use of
Misoprostol in the Gravid Patient With a Previous Cesarean Section. In : American Journal
of Obstetrics and Gynecology . 1999; 180: 1535 42.

Rasyid HA. Evaluasi Upaya Persalinan Pervaginam pada Kasus Bekas Seksio Sesarea di
RSUD. Dr. Pirngadi Medan. 1992.

Rozenberg P, Goffinet F, Phillippe H, et al. Which Women Who Have Had A Previous
Cesarean Section? In: Paper Ultrasonographic Measurement of Uterine Segmen to Assess
Risk of Defects of Scared Uterus. In: Lancet. 1996; 347 : 281 4.

Salzmann B. Rupture of Low Segment Cesarean Section Score. Journal Obstetrics and
Gynecology. 1994: 23: 460 6.

Samil RS. Change Trend in Cesarean Section in Indonesia . Dalam: Majalah Obstetri &
Ginekologi Indonesia . 1988;14(2), 72-79

Scott JR. Avoiding Labor Problems During Vaginal Birth After Cesarean Delivery. In:
Clinical Obstetrics and Gynecology. 1997; 40: 533.

Spaans WA, Velde FH, Roosmalen VJ. Trial of Labor after Previous Cesarean Section in
Rural Zimbabwe . In: Europe Journal Obstetrics and Gynecology Reproduction Biologic.
1997; 72: 9 14.

31


Sulaini P . Tinjauan Persalinan Bekas Seksio Sesarea di RSUP Dr. M. Djamil Padang Tahun
1988-1990, Tesis untuk Brevet Spesialis Obstetri dan Ginekologi di FKUA Padang 1991

Toth P P, Jothivijayarani A. Vaginal Birth After Cesarean Section (VBAC) University
IOWA . In: Family Practice Hand Book. 3
rd
ed. 1996.

Troyer LR, Parisi VM. Obstetric Parameters affecting Success in A Trial of Labor.
Designation Skoring System. In: Journal Obstetrics and Gynecology. 1992; 167 : 1099 104.

Vaginal delivery in Patient with prior cesarean birth. In: American Journal of Obstetrics and
Gynecology. 1982; 59: 135-48

Weinstein D, Benshushan A, Tanos V, et al. Predictive Score for Vaginal Birth After
Cesarean Section. In: American Journal Obsterics and Gynecology . 1996; 174: 192 8

Zelop CM, Shipp TD, Repke JT, et al. Uterine Rupture During Inducted or Augmented Labor
in Gravid Women with One Prior Cesarean Delivery. In: American Journal Obsterics and
Gynecology. 1999; 181: 882 5.





a. PERUBAHAN ANATOMI DAN FISIOLOGI

UTERUS
Pada akhir kehamilan (40 minggu) berat uterus menjadi 1000 gram (berat uterus normal 30
gram) dengan panjang 20 cm dan dinding 2,5 cm. Pada bulan-bulan pertama kehamilan,
bentuk uterus seperti buah alpukat agak gepeng. Pada kehamilan 16 minggu, uterus berbentuk
bulat. Selanjutnya pada akhir kehamilan kembali seperti bentuk semula, lonjong seperti telur.
Hubungan antara besarnya uterus dengan tuanya kehamilan sangat penting diketahui antara
lain untuk membentuk diagnosis, apakah wanita tersebut hamil fisiologik, hamil ganda atau
menderita penyakit seperti mola hidatidosa dan sebagainya.
Pada kehamilan 28 minggu, fundus uteri terletak kira-kira 3 jari diatas pusat atau 1/3
jarak antara pusat ke prosssus xipoideus. Pada kehamilan 32 minggu, fundus uteri terletak antara
jarak pusat dan prossesus xipoideus. Pada kehamilan 36 minggu, fundus uteri terletak kira-
kira 1 jari dibawah prossesus xipoideus. Bila pertumbuhanjanin normal, maka tinggi fundus uteri
pada kehamilan 28 minggu adalah 25 cm, pada 32 minggu adalah 27 cm dan pada 36 minggu
adalah 30 cm. Pada kehamilan 40 minggu, fundus uteri turun kembali dan terletak kira-kira 3 jari
dibawah prossesus xipoideus. Hal ini disebabkan oleh kepala janin yang pada primigravida turun
dan masuk kedalam rongga panggul.
Pada trimester III, istmus uteri lebih nyata menjadi corpus uteri dan berkembang
menjadi segmen bawah uterus atau segmen bawah rahim (SBR). Pada kehamilan tua, kontraksi
otot-otot bagian atas uterus menyebabkan SBR menjadi lebih lebar dan tipis (tampak batas yang
nyata antara bagian atas yang lebih tebal dan segmen bawah yang lebih tipis). Batas ini dikenal
sebagai lingkaran retraksi fisiologik. Dinding uterus diatas lingkaran ini jauh lebih tebal daripada
SBR.
SERVIKS UTERI
32


Serviks uteri pada kehamilan juga mengalami perubahan karena hormon estrogen.
Akibat kadar estrogen yang meningkat dan dengan adanya hipervaskularisasi, maka konsistensi
serviks menjadi lunak. Serviks uteri lebih banyak mengandung jaringan ikat yang terdiri atas
kolagen. Karena servik terdiri atas jaringan ikat dan hanya sedikit mengandung jaringan otot,
maka serviks tidak mempunyai fungsi sebagai spinkter, sehingga pada saat partus serviks akan
membuka saja mengikuti tarikan-tarikan corpus uteri keatas dan tekanan bagian bawah janin
kebawah. Sesudah partus, serviks akan tampak berlipat-lipat dan tidak menutup seperti spinkter.
Perubahan-perubahan pada serviks perlu diketahui sedini mungkin pada kehamilan, akan tetapi
yang memeriksa hendaknya berhati-hati dan tidak dibenarkan melakukannya dengan kasar,
sehingga dapat mengganggu kehamilan.
Kelekjar-kelenjar di serviks akan berfungsi lebih dan akan mengeluarkan sekresi lebih
banyak. Kadang-kadang wanita yang sedang hamil mengeluh mengeluarkan cairan
pervaginam lebih banyak. Pada keadaan ini sampai batas tertentu masih merupakan keadaan
fisiologik, karena peningakatan hormon progesteron. Selain itu prostaglandin bekerja pada
serabut kolagen, terutama pada minggu-minggu akhir kehamilan. Serviks menjadi lunak dan
lebih mudah berdilatasi pada waktu persalinan.

VAGINA DAN VULVA
Vagina dan vulva akibat hormon estrogen juga mengalami perubahan. Adanya
hipervaskularisasi mengakibatkan vagina dan vula tampak lebih merah dan agak kebiru-
biruan (livide). Warna porsio tampak livide. Pembuluh-pembuluh darah alat genetalia interna
akan membesar. Hal ini dapat dimengerti karena oksigenasi dan nutrisi pada alat-alat
genetalia tersebut menigkat. Apabila terjadi kecelakaan pada kehamilan/persalinan maka
perdarahan akan banyak sekali, sampai dapat mengakibatkan kematian. Pada bulan terakhir
kehamilan, cairan vagina mulai meningkat dan lebih kental.
MAMMAE
Pada kehamilan 12 minggu keatas, dari puting susu dapat keluar cairan berwarna putih agak
jernih disebut kolostrum. Kolostrum ini berasal dari kelenjar-kelenjar asinus yang mulai
bersekresi.

SIRKULASI DARAH
Volume darah akan bertambah banyak 25% pada puncak usia kehamilan 32 minggu.
Meskipun ada peningkatan dalam volume eritrosit secara keseluruhan, tetapi penambahan
volume plasma jauh lebih besar sehingga konsentrasi hemoglobin dalam darah menjadi lebih
rendah. Walaupun kadar hemoglobin ini menurun menjadi 120 g/L. Pada minggu ke-32,
wanitahamil mempunyai hemoglobin total lebih besar daripada wanita tersebut ketika tidak
hamil. Bersamaan itu, jumlah sel darah putih meningkat ( 10.500/ml), demikian juga hitung
trombositnya.
Untuk mengatasi pertambahan volume darah, curah jantung akan meningkat 30% pada
minggu ke-30. Kebanyakan peningkatan curah jantung tersebut disebabkan oleh
meningkatnya isi sekuncup, akan tetapi frekuensi denyut jantung meningkat 15%. Setelah
kehamilan lebih dari 30 minggu, terdapat kecenderungan peningkatan tekanan darah.
Sama halnya dengan pembuluh darah yang lain, vena tungkai juga mengalami distensi. Vena
tungkai terutama terpengaruhi pada kehamilan lanjut karena terjadi obstruksi aliran balik vena
(venous return) akibat tingginya tekanan darah vena yang kembali dari utrerus dan akibat
tekanan mekanik dari uterus pada vena kava. Keadaan ini menyebabkan varises pada vena
tungkai (dan kadang-kadang pada vena vulva) pada wanita yang rentan.
Aliran darah melalui kapiler kulit dan membran mukosa meningkat hingga mencapai
maksimum 500 ml/menit pada minggu ke-36. Peningkatan aliran darah pada kulit
disebabkanoleh vasodilatasi ferifer. Hal ini menerangkan mengapa wanita merasa panas
mudah berkeringat, sering berkeringat banyak dan mengeluh kongesti hidung.
Gambaran protein dalam serum berubah, jumlah protein, albumin, dan gamma globulin baru
meningkat perlahan-lahan pada akhir kehamilan, sedangkan beta globulin dan bagian-bagian
fibrinogen terus meningkat. LED pada umumnya meningkat sampai 4x sehingga dalam
kehamilan tidak dapat dipakai sebagai ukuran.

SISTEM RESPIRASI
Pernafasan masih diafragmatik selama kehamilan, tetapi karena pergerakan diafragma terbatas
setelah minggu ke-30, wanita hamil bernafas lebih dalam, dengan meningkatkan volume tidal
dan kecepatan ventilasi, sehingga memungkinkan pencampuran gas meningkat dan konsumsi
oksigen meningkat 20%. Diperkirakan efek ini disebabkan oleh meningkatnya sekresi
progesteron. Keadaan tersebut dapat menyebabkan pernafasan berlebih dan PO2 arteri lebih
33


rendah. Pada kehamilan lanjut, kerangka iga bawah melebar keluar sedikit dan mungkin tidak
kembali pada keadaan sebelum hamil, sehingga menimbulkan kekhawatiran bagi wanita yang
memperhatikan penampilan badannya.

TRAKTUS DIGESTIFUS
Di mulut, gusi menjadi lunak, mungkin terjadi karena retensi cairan intraseluler yang
disebabkan oleh progesteron. Spinkter esopagus bawah relaksasi, sehingga dapat terjadi
regorgitasi isilambung yang menyebabkan rasa terbakar di dada (heathburn). Sekresi
isilambungberkurang dan makanan lebih lama berada di lambung. Otot-otot usus relaks dengan
disertai penurunan motilitas. Hal ini memungkinkan absorbsi zat nutrisi lebih banyak, tetapi
dapat menyebabkan konstipasi, yang memana merupakan salah satu keluhan utamawanita hamil.

TRAKTUS URINARIUS
Pada akhir kehamilan, kepala janin mulai tuun ke PAP, keluhan sering kencing dan
timbul lagi karena kandung kencing mulai tertekan kembali. Disamping itu, terdapat pula poliuri.
Poliuri disebabkan oleh adanya peningkatan sirkulasi darah di ginjal pada kehamilan sehingga
laju filtrasi glomerulus juga meningkat sampai 69%. Reabsorbsi tubulus tidak berubah, sehingga
produk-produk eksresi seperti urea, uric acid, glukosa, asam amino, asam folik lebih banyak
yang dikeluarkan.

SISTEM IMUN
HCG dapat menurunkan respon imun wanita hamil. Selain itu kadar Ig G, Ig A dan Ig M
serum menurun mulai dari minggu ke-10 kehamilan hingga mencapai kadar terendah pada
minggu ke-30 dan tetap berada pada kadar ini, hingga aterm.

METABOLISME DALAM KEHAMILAN
BMR meningkat hingga 15-20% yang umumnya ditemukan pada trimester III. Kalori
yang dibutuhkan untuk itu diperoleh terutama dari pembakaran karbohidrat, khususnya sesudah
kehamilan 20 minggu ke atas. Akan tetapi bila dibutuhkan, dipakailah lemak ibu untuk
mendapatkan tambahan kalori dalam pekerjaan sehari-hari. Dalam keadaan biasa wanita hamil
cukup hemat dalam hal pemakaian tenaganya.
Janin membutuhkan 30-40 gr kalsium untuk pembentukan tulang-tulangnya dan hal ini terjadi
terutama dalam trimester terakhir. Makanan tiap harinya diperkirakan telah mengandung 1,5-
2,5 gr kalsium. Diperkirakan 0,2-0,7 gr kalsium tertahan dalam badan untuk keperluan semasa
hamil. Ini kiranya telah cukup untuk pertumbuhan janin tanpa mengganggu kalsium ibu.
Kadar kalsium dalam serum memang lebih rendah, mungkin oleh karena adanya hidremia,
akan tetapi kadar kalsium tersebut masih cukup tinggi hingga dapat menanggulangi
kemungkinan terjadinya kejang tetani.
Segera setelah haid terlambat, kadar enzim diamino-oksidase (histamine) meningkat
dari 3-6 satuan dalam masa tidak hamil ke 200 satuan dalam masa hamil 16 minggu. Kadar ini
mencapai puncaknya sampai 400-500 satuan pada kehamilan 16 minggu dan seterusnya sampai
akhir kehamilan.Pinosinase adalah enzim yang dapat membuat oksitosin tidak aktif. Pinositase
ditemukan banyak sekali di dalam darah ibu pada kehamilan 14-38 minggu.
Berat badan wanita hamil akan naik kira-kira diantara 6,5-16,5 kg rata-rata 12,5 kg.
Kenaikan berat badan ini terjadi terutama dalam kehamilan 20 minggu terakhir. Kenaikan berat
badan dalam kehamilan disebabkan oleh hasil konsepsi, fetus placenta dan liquor.

b. PERUBAHAN PSIKOLOGI
Trimester III ditandai dengan klimaks kegembiraan emosi karena kelahiran bayi. Sekitar
bulan ke-8 mungkin terdapat periode tidak semangat dan depresi, ketika bayi membesar dan
ketidaknyamanan bertambah. Calon ibu mudah lelah dan menunggu dampaknya terlalau lama.
Sekitar 2 minggu sebelum melahirkan, sebagian besar wanita mulai mengalami perasaan senang.
Mereka mungkin mengatakan pada perawat saya merasa lebih baikan saat ini ketimbang
sebulan yang lalu. Kecuali bila berkembang masalah fisik, kegembiraan ini terbawa sampai
proses persalinan, suatu periode dengan stress yang tinggi.
Reaksi calon ibu terhadap persalinan ini secara umum tergantung pada persiapan dan
persepsinya terhadap kejadian ini. Kerjasama yanh khusus slama peristiwa ini akan dibicarakan
dalam hubungannya dengan askep yang diberikan padanya. Perasaan sangat gembira yang
dialami ibu seminggu sebelum persalinan mencapai klimaksnya sekitar 24 jam sebelum
persalinan.

SUMBER :
34


Farrer, Helen. 2001. Perawatan Maternitas Edisi 2. Jakarta : EGC.

Manuaba, IBG. 1998. Ilmu Kebidanan, Penyakit Kandungan dan Keluarga Berencana Untuk
Pendidikan Bidan. Jakarta : EGC.


Saifuddin, AB. 2002. Buku Panduan Praktis Pelayanan Kesehatan Maternal dan Neonatal.
Jakarta: Yayasan Bina Pustaka Sarwono Prawirohardjo.

Sarwono, R. Prawiro. 1999. Ilmu Kebidanan. Jakarta: Yayasan Bina Pustaka






Ultrasonographic measurement of lower uterine segment to assess risk of defects of scarred
uterus.
Rozenberg P, Goffinet F, Phillippe HJ, Nisand I.
Department of Obstetrics and Gynaecology, Centre Hospitalier Intercommunal, Leon Touhladjian,
Poissy, France.
BACKGROUND: Ultrasonography has been used to examine the scarred uterus in women
who have had previous caesarean sections in an attempt to assess the risk of rupture of the
scar during subsequent labour. The predictive value of such measurements has not been
adequately assessed, however. We aimed to evaluate the usefulness of sonographic
measurement of the lower uterine segment before labour in predicting the risk of
intrapartum uterine rupture. METHODS: In this prospective observational study, the
obstetricians were not told the ultrasonographic findings and did not use them to make
decisions about type of delivery. Eligible patients were those with previous caesarean
sections booked for delivery at our hospital. 642 patients underwent ultrasound
examination at 36-38 weeks' gestation, and were allocated to four groups according to the
thickness of the lower uterine segment. Ultrasonographic findings were compared with
those of physical examination at delivery. FINDINGS: The overall frequency of defective
scars was 4.0% (15 ruptures, 10 dehiscences). The frequency of defects rose as the
thickness of the lower uterine segment decreased: there were no defects among 278
women with measurements greater than 4.5 mm, three (2%) among 177 women with
values of 3.6-4.5 mm, 14 (10%) among 136 women with values of 2.6-3.5 mm, and eight
(16%) among 51 women with values of 1.6-2.5 mm. With a cut-off value of 3.5 mm, the
sensitivity of ultrasonographic measurement was 88.0%, the specificity 73.2%, positive
predictive value 11.8%, and negative predictive value 99.3%. INTERPRETATION: Our
results show that the risk of a defective scar is directly related to the degree of thinning of
the lower uterine segment at around 37 weeks of pregnancy. The high negative predictive
value of the method may encourage obstetricians in hospitals where routine repeat elective
caesarean is the norm to offer a trial of labour to patients with a thickness value of 3.5 mm
or greater.
PMID: 8569360 [PubMed - indexed for MEDLINE]


SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth.
Number 155 (Replaces guideline Number 147), February 2005.
Society of Obstetricians and Gynaecologists of Canada.
OBJECTIVE: To provide evidence-based guidelines for the provision of a trial of labor (TOL)
after Caesarean section. OUTCOME: Fetal and maternal morbidity and mortality associated
with vaginal birth after Caesarean (VBAC) and repeat Caesarean section. EVIDENCE:
35


MEDLINE database was searched for articles published from January 1, 1995, to February
28, 2004, using the key words "vaginal birth after Caesarean (Cesarean) section". The
quality of evidence is described using the Evaluation of Evidence criteria outlined in the
Report of the Canadian Task Force on the Periodic Health Exam. RECOMMENDATIONS: 1.
Provided there are no contraindications, a woman with 1 previous transverse low-segment
Caesarean section should be offered a trial of labor (TOL) with appropriate discussion of
maternal and perinatal risks and benefits. The process of informed consent with appropriate
documentation should be an important part of the birth plan in a woman with a previous
Caesarean section (II-2B). 2. The intention of a woman undergoing a TOL after Caesarean
section should be clearly stated, and documentation of the previous uterine scar should be
clearly marked on the prenatal record (II-2B). 3. For a safe labor after Caesarean section, a
woman should deliver in a hospital where a timely Caesarean section is available. The
woman and her health care provider must be aware of the hospital resources and the
availability of obstetric, anesthetic, pediatric, and operating-room staff (II-2A). 4. Each
hospital should have a written policy in place regarding the notification and (or) consultation
for the physicians responsible for a possible timely Caesarean section (III-B). 5. In the case
of a TOL after Caesarean, an approximate time frame of 30 min should be considered
adequate in the set-up of an urgent laparotomy (IIIC). 6. Continuous electronic fetal
monitoring of women attempting a TOL after Caesarean section is recommended (II-2A). 7.
Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt
to decrease maternal and perinatal morbidity and mortality (II-2A). 8. Oxytocin
augmentation is not contraindicated in women undergoing a TOL after Caesarean section
(II-2A). 9. Medical induction of labor with oxytocin may be associated with an increased risk
of uterine rupture and should be used carefully after appropriate counseling (II-2B). 10.
Medical induction of labor with prostaglandin E2 (dinoprostone) is associated with an
increased risk of uterine rupture and should not be used except in rare circumstances and
after appropriate counseling (II-2B). 11. Prostaglandin E1 (misoprostol) is associated with a
high risk of uterine rupture and should not be used as part of a TOL after Caesarean section
(II-2A). 12. A foley catheter may be safely used to ripen the cervix in a woman planning a
TOL after Caesarean section (II-2A). 13. The available data suggest that a trial of labor in
women with more than 1 previous Caesarean section is likely to be successful but is
associated with a higher risk of uterine rupture (II-2B). 14. Multiple gestation is not a
contraindication to TOL after Caesarean section (II-2B). 15. Diabetes mellitus is not a
contraindication to TOL after Caesarean section (II-2B). 16. Suspected fetal macrosomia is
not a contraindication to TOL after Caesarean section (II-2B). 17. Women delivering within
18-24 months of a Caesarean section should be counseled about an increased risk of
uterine rupture in labor (II-2B). 18. Postdatism is not a contraindication to a TOL after
Caesarean section (II-2B). 19. Every effort should be made to obtain the previous
Caesarean section operative report to determine the type of uterine incision used. In
situations where the scar is unknown, information concerning the circumstances of the
previous delivery is helpful in determining the likelihood of a low transverse incision. If the
likelihood of a lower transverse incision is high, a TOL after Caesarean section can be
offered (II-2B). VALIDATION: These guidelines were approved by the Clinical Practice
Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of
Canada.
PMID: 16001462 [PubMed - indexed for MEDLINE]



: Lancet. 1996 Feb 3;347(8997):281-4. Links
Comment in:
Lancet. 1996 Feb 3;347(8997):278.
Lancet. 1996 Mar 23;347(9004):838-9.
Ultrasonographic measurement of lower uterine segment to assess risk of defects of scarred
uterus.
Rozenberg P, Goffinet F, Phillippe HJ, Nisand I.
36


Department of Obstetrics and Gynaecology, Centre Hospitalier Intercommunal, Leon Touhladjian, Poissy,
France.
BACKGROUND: Ultrasonography has been used to examine the scarred uterus in women who
have had previous caesarean sections in an attempt to assess the risk of rupture of the scar
during subsequent labour. The predictive value of such measurements has not been
adequately assessed, however. We aimed to evaluate the usefulness of sonographic
measurement of the lower uterine segment before labour in predicting the risk of
intrapartum uterine rupture. METHODS: In this prospective observational study, the
obstetricians were not told the ultrasonographic findings and did not use them to make
decisions about type of delivery. Eligible patients were those with previous caesarean
sections booked for delivery at our hospital. 642 patients underwent ultrasound examination
at 36-38 weeks' gestation, and were allocated to four groups according to the thickness of
the lower uterine segment. Ultrasonographic findings were compared with those of physical
examination at delivery. FINDINGS: The overall frequency of defective scars was 4.0% (15
ruptures, 10 dehiscences). The frequency of defects rose as the thickness of the lower
uterine segment decreased: there were no defects among 278 women with measurements
greater than 4.5 mm, three (2%) among 177 women with values of 3.6-4.5 mm, 14 (10%)
among 136 women with values of 2.6-3.5 mm, and eight (16%) among 51 women with
values of 1.6-2.5 mm. With a cut-off value of 3.5 mm, the sensitivity of ultrasonographic
measurement was 88.0%, the specificity 73.2%, positive predictive value 11.8%, and
negative predictive value 99.3%. INTERPRETATION: Our results show that the risk of a
defective scar is directly related to the degree of thinning of the lower uterine segment at
around 37 weeks of pregnancy. The high negative predictive value of the method may
encourage obstetricians in hospitals where routine repeat elective caesarean is the norm to
offer a trial of labour to patients with a thickness value of 3.5 mm or greater.
PMID: 8569360 [PubMed - indexed for MEDLINE]



1: Obstet Gynecol. 2000 Apr;95(4):596-600. Links
Predicting incomplete uterine rupture with vaginal sonography during the late second trimester
in women with prior cesarean.
Gotoh H, Masuzaki H, Yoshida A, Yoshimura S, Miyamura T, Ishimaru T.
Department of Obstetrics and Gynecology, Nagasaki University School of Medicine, Nagasaki, Japan.
OBJECTIVE: To evaluate the usefulness of serial transvaginal ultrasonographic measurement
of the thickness of the lower uterine segment in the late second trimester for predicting the
risk of intrapartum incomplete uterine rupture in women with previous cesarean delivery.
METHODS: Serial transvaginal ultrasonography with full bladder was performed in 374
women without previous cesarean delivery (control group) and 348 women with previous
cesarean delivery (cesarean group) from 19 to 39 weeks' gestation. The thickness of the
lower uterine segment was measured in the longitudinal plane of the cervical canal.
RESULTS: The thickness of the lower uterine segment decreased from 6.7 +/- 2.4 mm
(mean +/- standard deviation [SD]) at 19 weeks' gestation to 3.0 +/- 0.7 mm at 39 weeks'
gestation in the control group, but the thickness was more than 2.0 mm throughout this
period in each control subject. In the cesarean group, the thickness decreased from 6.8 +/-
2.3 mm at 19 weeks' to 2.1 +/- 0.7 mm at 39 weeks' gestation and was significantly thinner
than that of the control group after 27 weeks' gestation (P <.05). Eleven of 12 women (91%)
with lower uterine segment less than the mean control - 1 SD in the late second trimester
had a very thin lower uterine segment at cesarean delivery with fetal hair being visible
through the amniotic membrane, ie, incomplete uterine rupture. In 17 of 23 women (74%)
with lower uterine segment less than 2.0 mm in thickness within 1 week (4 +/- 3 days)
before repeat cesarean delivery, intrapartum incomplete uterine rupture developed.
CONCLUSION: Transvaginal ultrasonography is useful for measurement of the uterine wall
after previous cesarean delivery.
37


PMID: 10725496 [PubMed - indexed for MEDLINE]
Related articles
Second-trimester sonographic comparison of the lower uterine
segment in pregnant women with and without a previous cesarean
delivery.
J Ultrasound Med. 2004 Jul; 23(7):907-11; quiz 913-4.
[J Ultrasound Med. 2004]
Sonographic measurement of the lower uterine segment thickness in
women with previous caesarean section.
J Obstet Gynaecol Can. 2005 Jul; 27(7):674-81.
[J Obstet Gynaecol Can. 2005]
[Echographic measurement of the inferior uterine segment for
assessing the risk of uterine rupture]
J Gynecol Obstet Biol Reprod (Paris). 1997; 26(5):513-9.
[J Gynecol Obstet Biol Reprod (Paris). 1997]
ReviewUterine rupture in second-trimester misoprostol-induced
abortion after cesarean delivery: a systematic review.
Obstet Gynecol. 2009 May; 113(5):1117-23.
[Obstet Gynecol. 2009]
ReviewTransvaginal sonographic measurement of cervical length to
predict preterm birth in asymptomatic women at increased risk: a
systematic review.
Ultrasound Obstet Gynecol. 2008 May; 31(5):579-87.
[Ultrasound Obstet Gynecol. 2008]
See reviews... | See all...




Predicting uterine rupture via sonogram to measure
uterine thickness
A couple weeks ago Virginia from Switzerland left this comment:
I am planning to have a vbac at a hospital in Geneva, Switzerland. In general, they are very supportive of
vbacs here.
It is common practice here to measure the uterine scar at 37 weeks using a sonogram. Apparently, if the scar
tissue is 3.5mm or higher - it is very unlikely for a rupture. Mine happens to be 2.95mm. The hospital staff tells
me I have a 3 - 4% chance of a rupture versus a standard .05% chance of rupture. They warned me that I will
be monitored heavily during the birth because of these factors. Do you know much about this theory or know
where I can find more information about this?
Typically the rate of rupture quoted for a woman with one prior bikini cut cesarean is about half a percent or
0.5%. The thickness of the uterine scar/wall and its relation to rupture is something Ive heard discussed
quite a bit, but have never personally researched.
My lay opinion? Intuitively, this makes sense. The thicker the uterus, the less likely one is to rupture.
However, where we do draw the line at what is thick enough? This is where studies come into play. There
are several studies that focus on measuring uterine thickness via ultrasound on women with prior cesareans,
ten of which are listed below, but none of them are large enough to make any definitive decisions. When
38


looking at something like uterine rupture that happens about half of a percent of the time, you need to include
thousands of test subjects in order to get an accurate assessment of the frequency of the occurrence. We just
dont have that here. These are interesting preliminary studies that should be duplicated using thousands of
women. If there is a way to accurately predict which scars will rupture, this is important information to have,
but there is currently insufficient evidence available.
No Study total # of
women
# of women
with prior
cesarean
Notes
1 Rozenberg 1996 642 642 calculates
rupture by
uterine
thickness
2 Cheung 2004 133 53 compares
scarred (1.9
1.4 mm),
unscarred w/
1st pg 2.3
1.1 mm; P >
.05 , and
unscarred w/
2nd or more
pg (3.4 2.2
mm; P < .001)
3 Gotoh 2000 722 348 compares
scarred &
unscarred
4 Sen 2004 121 71 compares
scarred &
unscarred
5 Qureshi 1997 43 43 calculates
rupture by
uterine
thickness
6 Michaels 1998 70 58 compares
scarred &
unscarred
7 Rozenberg 1999 198 198
8 Montanari 1999 61 61 average
thickness =
3.82 mm +/-
0.99 mm
9 Cheung 2005 102 102
10 Asakura 2000 186 186
If you, like Virigina, are faced with a minimum uterine thickness standard, request the research your doctor
cites and look it up.
39


If you know of a large study, please leave a comment below with the study citation.
For those who like to skim, Ive bolded the most interesting parts of the abstracts.
More more information on the subject, check out Sonographic Measurement of the Lower Uterine
Segment Thickness: Is it Truly Predictive of Uterine Rupture? by Vincent Y.T. Cheung, MBBS, FRCOG,
FRCSC, Department of Obstetrics and Gynaecology, North York General Hospital, University of Toronto,
Toronto ON. It was published in February 2008 and has a great bibliography.
Study #1: Ultrasonographic measurement of lower uterine segment to assess risk of defects of
scarred uterus.
Rozenberg P, Goffinet F, Phillippe HJ, Nisand I. Lancet. 1996 Feb 3;347(8997):281-4. Department of
Obstetrics and Gynaecology, Centre Hospitalier Intercommunal, Leon Touhladjian, Poissy, France.

Lower uterine segment
thickness
Number of cases Number of ruptures
Greater than 4.5 mm 278 0
3.6 - 4.5 mm 177 3 (2%)
2.6 - 3.5 mm 136 14 (10%)
1.6 - 2.5 mm 51 8 (16%)
The high negative predictive value of the method may encourage obstetricians in hospitals where routine
repeat elective caesarean is the norm to offer a trial of labour to patients with a thickness value of 3.5 mm or
greater.
Study #2: Sonographic Evaluation of the Lower Uterine Segment in Patients With Previous
Cesarean Delivery.
Vincent Y. T. Cheung, MBBS, FRCOG, FRCSC, RDMS, Oana C. Constantinescu, MD, RDMS and Birinder S.
Ahluwalia, MBBS, RDMS. J Ultrasound Med 23:1441-1447 0278-4297. Department of Obstetrics and
Gynecology, North York General Hospital, Toronto, Ontario, Canada (V.Y.T.C.); and BSA Diagnostic Imaging,
Toronto, Ontario, Canada (O.C.C., B.S.A.).
Objective. To evaluate the appearance of the lower uterine segment (LUS) in pregnant women with previous
cesarean delivery and to compare the LUS thickness with that in women with unscarred uteri. Methods. In a
prospective study, sonographic examination was performed on 53 pregnant women with previous cesarean
delivery (cesarean group), 40 nulliparas (nullip-control), and 40 women who had 1 or more childbirths
with unscarred uteri (multip-control) between 36 and 38 weeks gestation to assess the appearance and
compare the thickness of the LUS. In the cesarean group, the sonographic findings were correlated with the
delivery outcome and the intraoperative LUS appearance. Results. In the cesarean group, 44 patients
(83.0%) had a normal-appearing LUS indistinguishable from that of control groups; 2 patients
(3.8%) had an LUS defect suggestive of dehiscence; and 7 patients (13.2%) had thickened areas of increased
echogenicity with or without myometrial thinning. Although the cesarean group had a thinner LUS (1.9
1.4 mm) when compared with both the nullip-control group (2.3 1.1 mm; P > .05) and the
multip-control group (3.4 2.2 mm; P < .001), only the latter difference achieved statistical significance.
One of the 2 patients who had a sonographically suspected LUS defect had confirmed uterine dehiscence
during surgery. An intraoperatively diagnosed paper-thin LUS, when compared with an LUS of normal
thickness, had significantly smaller sonographic LUS measurements (1.1 0.6 versus 2.0 0.8 mm,
respectively; P = .004). Conclusions. Prior cesarean delivery is associated with a sonographically thinner LUS
when compared with those with prior vaginal delivery. Prenatal sonographic examination is potentially capable
of diagnosing a uterine defect and determining the degree of LUS thinning in patients with previous cesarean
delivery.
This is the most interesting study because it compares scarred uteri to unscarred uteri that are pregnant for
the first time to unscarred uteri that are pregnant for at least the second time. I think this study is important
because when creating a uterine thickness standard, its important to understand what is a safe thickness.
How thick is an unscarred uterus in its first pregnancy and subsequent pregnancies? We can then compare
this standard to unscarred uteri. It is fascinating that 83% of the scarred uteri were indistinguishable from
40


the unscarred uteri. Since we are dealing with such small numbers here, 133 women total, it would be
irresponsible to create a thickness standard based on this study alone. If this same study was performed on
10,000 women from each category, that would be a study whose findings would be powerful enough to
rightfully influence VBAC policy.
Study #3: Predicting incomplete uterine rupture with vaginal sonography during the late second
trimester in women with prior cesarean.
Gotoh H, Masuzaki H, Yoshida A, Yoshimura S, Miyamura T, Ishimaru T. Obstet Gynecol. 2000 Apr;95(4):596-
600. Department of Obstetrics and Gynecology, Nagasaki University School of Medicine, Nagasaki, Japan.
OBJECTIVE: To evaluate the usefulness of serial transvaginal ultrasonographic measurement of the thickness
of the lower uterine segment in the late second trimester for predicting the risk of intrapartum incomplete
uterine rupture in women with previous cesarean delivery. METHODS: Serial transvaginal ultrasonography with
full bladder was performed in 374 women without previous cesarean delivery (control group) and
348 women with previous cesarean delivery (cesarean group) from 19 to 39 weeks gestation. The
thickness of the lower uterine segment was measured in the longitudinal plane of the cervical canal. RESULTS:
The thickness of the lower uterine segment decreased from 6.7 +/- 2.4 mm (mean +/- standard deviation
[SD]) at 19 weeks gestation to 3.0 +/- 0.7 mm at 39 weeks gestation in the control group, but the
thickness was more than 2.0 mm throughout this period in each control subject. In the cesarean
group, the thickness decreased from 6.8 +/- 2.3 mm at 19 weeks to 2.1 +/- 0.7 mm at 39 weeks
gestation and was significantly thinner than that of the control group after 27 weeks gestation
(P <.05). Eleven of 12 women (91%) with lower uterine segment less than the mean control - 1 SD in the
late second trimester had a very thin lower uterine segment at cesarean delivery with fetal hair being visible
through the amniotic membrane, ie, incomplete uterine rupture. In 17 of 23 women (74%) with lower uterine
segment less than 2.0 mm in thickness within 1 week (4 +/- 3 days) before repeat cesarean delivery,
intrapartum incomplete uterine rupture developed. CONCLUSION: Transvaginal ultrasonography is useful for
measurement of the uterine wall after previous cesarean delivery.
Study #4: Ultrasonographic evaluation of lower uterine segment thickness in patients of previous
cesarean section
S. Sen, S. Malik and S. Salhan. International Journal of Gynecology & Obstetrics Volume 87, Issue 3,
December 2004, Pages 215-219
Objective
To evaluate by ultrasonography, the lower uterine segment thickness of women with a previous cesarean
delivery and determine a critical thickness above which safe vaginal delivery is predictable.
Methods
A prospective observational study of 71 antenatal women with previous cesarean delivery and 50 controls was
carried out. Transabdominal and transvaginal ultrasonography were used in both groups to evaluate lower
uterine segment thickness. The obstetric outcome in patients with successful vaginal birth and intraoperative
findings in women undergoing cesarean delivery were correlated with lower segment thickness.
Results
The overall vaginal birth after cesarean section (VBAC) was 46.5% and VBAC success rate was 63.5%, the
incidence of dehiscence was 2.82%, and there were no uterine ruptures. There was a 96% correlation
between transabdominal ultrasonography with magnification and transvaginal ultrasonography. The critical
cutoff value for safe lower segment thickness, derived from the receiver operator characteristic curve, was 2.5
mm.
Conclusion
Ultrasonographic evaluation permits better assessment of the risk of scar complication intrapartum, and could
allow for safer management of delivery.
Study #5: Ultrasonographic evaluation of lower uterine segment to predict the integrity and
quality of cesarean scar during pregnancy: a prospective study.
Qureshi B, Inafuku K, Oshima K, Masamoto H, Kanazawa K. Tohoku J Exp Med 1997 Sep;183(1):55-65.
Department of Obstetrics and Gynecology, School of Medicine, University of the Ryukyus, Okinawa, Japan.
Table 4: Distribution of delivery mode by lower uterine segment thickness
Lower uterine
segment
Number Elective Successful Failed TOL
41


thickness of cases C/S TOL
Greater than 2
mm
28 6 (21.4%) 13 (46.4%) 9 (32.1%)
Equal to 2mm 7 5 (42.9%) 2 (28.6%) 2 (28.6%)
Less than 2 mm 8 8 (100%) 0 0
Total 43 17 (39.5%) 15 (34.9%) 11 (25.6%)
They concluded:
2 mm of thickness of the LUS was considered as good healing and less than 2 mm of thickness as poor
healingTwenty two (79%) of 28 women with a well healed scar had trial labor with the result that 46% had a
successful vaginal birth without any uterine rupture of dehiscence. Eight women with poor healing all had
elective C/S. Seven women with a 2 mm LUS thickness were individually categorized for delivery mode. Two of
those women delivered vaginally. The LUS was found to be thin to translucent in these later two groups.
Study #6: Ultrasound diagnosis of defects in the scarred lower uterine segment during
pregnancy.
Michaels WH, Thompson HO, Boutt A, Schreiber FR, Michaels SL, Karo J. Obstet Gynecol. 1988 Jan;71(1):112-
20. Department of Obstetrics and Gynecology, Providence Hospital, Southfield, Michigan.
A prospective study was begun using ultrasound to diagnose defects in the lower uterine segment. Seventy
patients were examined and delivered by cesarean section, including 58 at risk because of previous
cesarean section and 12 nulliparous controls not at risk. Of the at-risk patients, 12 had confirmed
defects, for an incidence of 20.7%. All the controls were normal. The false-positive rate for at-risk patients
was 7.1%, and the positive and negative predictive values were 92.3 and 100%, respectively. For the
diagnosed cases, the sonographic lower uterine segment seemed to form earlier (P less than .01) and was
thinner (P less than .01) than that in the negative cases or the controls. Although our study design was
observational and did not allow us to test the performance of the lower uterine segment when a defect was
found, we discuss the use of a three-stage classification system to assist in identifying sonographically detected
defects in a future trial of labor protocol. We conclude that sonographic surveillance is a reliable and practical
means of evaluating the lower uterine segment after conception and before labor or delivery.
Study #7: Thickness of the lower uterine segment: its influence in the management of patients
with previous cesarean sections.
Rozenberg P, Goffinet F, Philippe HJ, Nisand I. Eur J Obstet Gynecol Reprod Biol 1999 Nov;87(1):39-45.
Department of Gynecology and Obstetrics, Poissy Hospital, University Paris V, France.
gynobs.poissy@wanadoo.fr
OBJECTIVE: To determine how ultrasound measurement of the lower uterine segment affects the decision
about delivery for patients with previous cesarean sections (CS) and what are the consequences on cesarean
section rates and uterine rupture or dehiscence. DESIGN: Prospective open study. PATIENTS: 198 patients:
all women with a previous CS who gave birth in our department during 1995 and 1996 to an infant with a
gestational age of at least 36 weeks and who underwent ultrasound measurement of their lower uterine
segment (95-96 study group), compared with a similar population from 1989 to 1994 whose measurements
were not provided to the treating obstetrician. RESULTS: Among the patients with one previous CS, the vaginal
delivery rate did not differ significantly during the two periods (70.3% for the 89-94 study period vs. 67.9% for
the 95-96 study period, P=0.53), but the 95-96 study group experienced a significant increase in the rate of
elective CS, compensated by a reduction in the rate of emergency CS (6.3% and 23.4%, respectively, for the
89-94 study period vs. 11.9% and 20.1% for the 95-96 study period, P=0.01). There was a very significant
increase in the rate of vaginal delivery for the 95-96 study period among patients with two
previous CS (26.7% vs. 8.0% for the 89-95 study period, P=0.01). The lower uterine segment
was significantly thicker among women with a trial of labor than among those with an elective CS
(4.5+/-1.4 mm compared with 3.8 +/- 1.5 mm; P=0.006); and the trial of labor group contained
significantly fewer women with a lower uterine segment measurement less than 3.5 mm than did the elective
CS group (24.0% compared with 56.6%; P<0.001). Two patients (0.8%) were found to have a defect of the
uterine scar, a rate significantly lower than that observed in the early group (3.9%, P=0.03). CONCLUSIONS:
Ultrasound measurement of the lower uterine segment can increase the safe use of trial of labor, because it
provides an additional element for assessing the risk of uterine rupture. PMID: 10579615, UI: 20044216
42


I could not find the full article of this study, only the abstract, so I dont know if the women were permitted to
select their delivery mode or if it was determined by their uterine thickness.
Study #8: [Transvaginal ultrasonic evaluation of the thickness of the section of the uterine wall in
previous cesarean sections]. [Article in Italian]
Montanari L, Alfei A, Drovanti A, Lepadatu C, Lorenzi D, Facchini D, Iervasi MT, Sampaolo P. Minerva Ginecol
1999 Apr;51(4):107-12. Istituto di Clinica Ostetrica e Ginecologica, Universita degli Studi, IRCCS San Matteo,
Pavia.
BACKGROUND: The aim of this study is to evaluate accuracy of transvaginal sonographic examination of the
lower uterine segment in pregnant women with previous cesarean section. METHODS: Sixty-one pregnant
women between 37 and 40 weeks of gestation, with previous cesarean section underwent transvaginal
ultrasonography. Wall thickness of the lower uterine segment, the length of cervix, dilation of the isthmus uteri
were measured. On the basis of the surgical findings (in 53 patients) and outcome of the trial of labor (in
8 patients) a Score was assigned to the pregnant women: Score 1 to the women who had good healing or a
trial of labor without complications; Score 2 to the women with a thin or discontinued scar and in case of
threatened rupture of the uterus in the trial of labor. RESULTS: The mean thickness of the lower uterine
segment is 3.82 mm +/- 0.99 mm. The Score 1 group shows a mean thickness of 4.2 mm +/- 2.5
mm, and the Score 2 group a mean thickness of 2.8 mm +/- 1.06 mm. The transvaginal sonographic
examination provides a sensitivity and a specificity respectively of 100 and 75%, for a thickness cut-off of 3.5
mm, and a positive and negative predictive values of 60.7% and 100% respectively. CONCLUSIONS: The
transvaginal sonographic evaluation of the lower uterine segment improves therefore the obstetrical decision-
making regarding the trial of labor in women with previous cesarean section. PMID: 10379144, UI: 99307817
Study #9: Sonographic measurement of the lower uterine segment thickness in women with
previous caesarean section.
Cheung VY. J Obstet Gynaecol Can. 2005 Jul;27(7):674-81. Department of Obstetrics and Gynaecology, North
York General Hospital, Toronto, ON.
OBJECTIVES: To evaluate the accuracy of prenatal sonography in determining the lower uterine segment (LUS)
thickness in women with previous Caesarean section and to assess the usefulness of measuring LUS thickness
in predicting the risk of uterine rupture during a trial of vaginal birth. METHODS: Sonographic examination was
performed in 102 pregnant women with one or more previous Caesarean sections at between 36 and 38
weeks gestation to assess the LUS thickness, which was defined as the shortest distance between the urinary
bladder wall-myometrium interface and the myometrium/chorioamniotic membrane-amniotic fluid interface. Of
the 102 women examined, 91 (89.2%) had transabdominal sonography only, and 11 (10.8%) had both
transabdominal and transvaginal examinations. The sonographic measurements were correlated with the
delivery outcome and the intraoperative LUS appearance. RESULTS: The mean sonographic LUS thickness
was 1.8 mm, standard deviation (SD) 1.1 mm. An intraoperatively diagnosed paper-thin or
dehisced LUS, when compared with an LUS of normal thickness, had a significantly smaller
sonographic LUS measurement (0.9 mm, SD 0.5 mm, vs. 2.0 mm, SD 0.8 mm, respectively; P <
0.0001). Two women had uterine dehiscence, both of whom had prenatal LUS thickness of < 1
mm. Thirty-two women (31.4%) had a successful vaginal delivery, with a mean LUS thickness of
1.9 mm, SD 1.5 mm; none had clinical uterine rupture. A sonographic LUS thickness of 1.5 mm had a
sensitivity of 88.9%, a specificity of 59.5%, a positive predictive value of 32.0%, and a negative predictive
value of 96.2% in predicting a paper-thin or dehisced LUS. CONCLUSIONS: Sonography permits accurate
assessment of the LUS thickness in women with previous Caesarean section and therefore can potentially be
used to predict the risk of uterine rupture during trial of vaginal birth.
Study #10: Prediction of Uterine Dehiscence by Measuring Lower Uterine Segment Thickness
Prior to the Onset of Labor. Evaluation by Transvaginal Ultrasonography.
Hirobumi Asakura, Akihito Nakai, Gen Ishikawa, Shyunji Suzuki and Tsutomu Araki. Journal of Nippon Medical
School. Vol. 67 (2000) , No. 5 pp352-356. Department of Obstetrics and Gynecology, Nippon Medical School.
Abstract
Objective: Lower uterine segment thickness was measured by transvaginal ultrasound examination and its
correlations with the occurrence of uterine dehiscence and rupture was examined.
Methods: The thickness of the muscular layer of the lower uterine segment was measured in 186 term
gravidas with previous uterine scars and its correlation with uterine dehiscence/rupture was investigated.
Results: Uterine dehiscence was found in 9 cases or 4.7%. There were no cases of the uterine
rupture. The thickness of the lower uterine segment among the gravidas with dehiscence was significantly
less in than those without dehiscence (p< 0.01). The cut-off value for the thickness of the lower uterine
segment was 1.6 mm as calculated by the receiver operating characteristic curve. The sensitivity was 77.8%;
specificity 88.6%; positive predictive value 25.9%; negative predictive value 98.7%.
Conclusion: Measurement of the lower uterine segment is useful in predicting the absence of dehiscence
among gravidas with previous cesarean section. If the thickness of the lower uterine segment is more than 1.6
mm, the possibility of dehiscence during the subsequent trials of labor is very small.
January 17th, 2009 | Category: Medical Studies, Uterine Rupture, VBAC | 6 comments
43



6 comments to Predicting uterine rupture via sonogram to
measure uterine thickness
Dr. Dave
January 18th, 2009 at 5:26 pm Reply
Sorry, but as long as we can get sued for a VBAC complication, I really dont care what the literature says.
Take away the legal risk and Cesarean rates will go down, VBAC rates will go up.
Dr. Loveless
January 18th, 2009 at 10:25 pm Reply
I disagree with the previous poster. Whenever we make a medical intervention there is risk involved. One of
the purposes of scientific study is to evaluate that risk and try to figure out which groups are most at risk. If
there were enough power in these studies to identify those who are most at risk for rupture, then we could
have real discussions with patients and that would, in turn, help to limit malpractice exposure as the consent
would be truly informed.
Uterine Thickness as a Predictor of Uterine Rupture Woman to Woman Childbirth Education
January 19th, 2009 at 4:07 pm Reply
[...] she looks at several small studies (if you know of any larger ones, let her know!) which looked at the risk
of uterine rupture in VBACs based on the thickness of the uterus, as measured by [...]
Gigi
March 30th, 2009 at 9:31 am Reply
I am not a doctor, but I am a scientist and a woman that has had a c section. I can say that been through
major abdominal surgery is no fun. I believe strongly that they should measure the uterine thickness of the
LUS and at least allow women that have 4.5 or more to deliver vaginally! while giving the informed option to
the others of potential consequences. For a example a 1 hour labour with LUS 3.6 would harly rupture.
Finally I would say that the amount of c sections whether primary or elective is unethical.
Gigi
March 30th, 2009 at 8:02 pm Reply
By the way Dr. Dave, have you ever thought that maybe one day you will be sued for an unecessary c section
or for complications resulting from it?
I am planning to sue actually my health provider for that reason, as he has put my future reproductive health
at risk by coercing me to unecessary surgery.
Leigha
May 11th, 2009 at 8:41 am Reply
I had a VBAC in 2008. When I was planning it, I did extensive research on this measurement (read every study
you listed) and corresponded with Dr. Rozenberg in France, author of study #1 on your list. I even had him
send me directions for the sonographer at my midwifes office on how to perform the measurement. I had it
done at 37 weeks (at my request - my midwife allowed me to have it done but did not introduce the idea). I
had a thickness of 4mm. I knew from the literature that this suggested I had a lower-than-average chance of
rupture so I felt very comfortable going through with the VBAC. It worked out great and I would do it all again.
I would not have felt comfortable going forward with my VBAC plans if I had had a measurement of under
3mm given the literature. I agree that it would be wonderful to have a larger study done on this.





44


Predicting incomplete uterine rupture with vaginal sonography during the late second
trimester in women with prior cesarean.
Obstet Gynecol. 2000; 95(4):596-600 (ISSN: 0029-7844)
Gotoh H; Masuzaki H; Yoshida A; Yoshimura S; Miyamura T; Ishimaru T
Department of Obstetrics and Gynecology, Nagasaki University School of Medicine, Nagasaki, Japan.
OBJECTIVE: To evaluate the usefulness of serial transvaginal ultrasonographic measurement of the thickness
of the lower uterine segment in the late second trimester for predicting the risk of intrapartum incomplete
uterine rupture in women with previous cesarean delivery. METHODS: Serial transvaginal ultrasonography with
full bladder was performed in 374 women without previous cesarean delivery (control group) and 348 women
with previous cesarean delivery (cesarean group) from 19 to 39 weeks' gestation. The thickness of the lower
uterine segment was measured in the longitudinal plane of the cervical canal. RESULTS: The thickness of the
lower uterine segment decreased from 6.7 +/- 2.4 mm (mean +/- standard deviation [SD]) at 19 weeks'
gestation to 3.0 +/- 0.7 mm at 39 weeks' gestation in the control group, but the thickness was more than 2.0
mm throughout this period in each control subject. In the cesarean group, the thickness decreased from 6.8 +/-
2.3 mm at 19 weeks' to 2.1 +/- 0.7 mm at 39 weeks' gestation and was significantly thinner than that of the
control group after 27 weeks' gestation (P <.05). Eleven of 12 women (91%) with lower uterine segment less
than the mean control - 1 SD in the late second trimester had a very thin lower uterine segment at cesarean
delivery with fetal hair being visible through the amniotic membrane, ie, incomplete uterine rupture. In 17 of 23
women (74%) with lower uterine segment less than 2.0 mm in thickness within 1 week (4 +/- 3 days) before
repeat cesarean delivery, intrapartum incomplete uterine rupture developed. CONCLUSION: Transvaginal
ultrasonography is useful for measurement of the uterine wall after previous cesarean delivery.


Modern Medicine - A New Resource for Busy Physicians & Healthcare Professionals
Click Here to Learn More

Ultrasound Clinics: Does U/S have a role in assessing uterine patency?
Source: Contemporary OB/GYN
By: Robert J. Stiller, MD, Benjamin D. Hamar, MD
Originally published: May 1, 2006

How to manage delivery in the woman who previously gave birth via cesarean? That is the subject of much
controversy in our specialty, even as cesarean rates rise despite the federal government's attempts to lower them.
1

Much effort has gone into trying to identify risk factors for uterine rupture so that we can predict which patients are
likely to have a successful vaginal birth after cesarean (VBAC).
2
With our country's increasing cesarean rates, too,
have come increased risks of placenta previa and accreta for women in subsequent pregnancies.
3-5
Ultrasound has
proved useful in helping to settle other obstetric controversies. Might it also have a role in assessing uterine scars
before pregnancy and predicting risk of uterine rupture? Let's examine the evidence.
Are scars significant?
In early studies of uterine scars, transabdominal U/S was used to distinguish between classical and transverse
uterine incisions. More recent efforts with transvaginal U/S have shown that it is more effective for such screening.
6

In 2001, Monteagudo and colleagues used saline infusion sonohysterography (SIS) to detect and characterize prior
uterine incisions. With this technique, saline is infused into the uterus during sonographic evaluation to distend the
uterus and delineate the endometrial cavity's contours. The authors found they could detect a "niche" ranging from
2.5 to 11.5 mm in the anterior uterine wall of all of the women who had previously delivered by cesarean.
7
In addition,
in 33% of the patients, the cesarean scar could be seen before the saline infusion as a fine, hyperechoic region
extending anteriorly from the "niche."
7
Monteagudo and colleagues speculated that risk of uterine dehiscence and
rupture might be related to the depth of the niche or the thickness of the overlying myometrium.
In another study using SIS, Regnard and colleagues investigated the frequency of sonographic dehiscence in women
with a history of cesarean delivery. They saw a "niche" in 57.5% of patients (Figure 1), and in 6% of patients, a "deep
niche" extending through 80% of the myometrium was visible.
8

There have been reports describing repair of uterine defects detected by U/S. One case report describes the repair of
a uterine dehiscence in pregnancy detected at 28 weeks' gestation with subsequent conservative management and
elective delivery at 35 weeks.
9
Another recent series describes the laparoscopic and vaginal repair of uterine defects
45


detected by U/S in five nongravid women. One woman in this series went on to have an uncomplicated, term repeat
C/S.
10

Whether these findingsand the depth of the niche-are clinically significant remains unknown. What we do know,
however, is that conventional U/S and SIS can be used to identify uterine scars in women who have delivered by
cesarean, before they become pregnant again. Several sonographic findings, including "deep niches," are suggestive
of a uterine wall defect, but it's unclear whether they have clinical significance or are related to subsequent uterine
rupture.
Intrapartum uterine rupture during a trial of labor after prior cesarean is rare, occurring in about 0.5% of women, when
cervical ripening with oxytocin or prostaglandin is not required.
11
Uterine niches, in contrast, are seen in 6% to 42% of
women who have delivered by cesarean, making them too common to show a clear relationship between a niche and
uterine rupture. Their clinical significance and relationship to adverse pregnancy outcomes also have yet to be
determined. At this time, repair of uterine niches is considered experimental.
What about scars at term?
U/S also has been used by clinicians to diagnose uterine rupture before the onset of labor, and recently, researchers
have tried to predict which women may be at increased risk of uterine rupture.
During pregnancy, the uterine wall gets progressively thinner. An unscarred uterus
decreases from a mean thickness of 6.7 mm in the second trimester to a mean of 3.0
mm by 39 weeks, but it will always measure more than 2.0 mm.
12,13
The uterus in a
woman with a history of cesarean delivery has a similar thickness early in pregnancy,
but is significantly thinner at term.
12
Figure 2 shows a typical sonogram of myometrial
thickness in a woman with a history of redundant cesarean delivery, which
demonstrates a normal lower uterine segment measured at the bladder reflection in the
second trimester. Whether there is a correlation between a thin lower uterine segment
on U/S and risk of uterine dehiscence and rupture is less clear.
Rozenberg and colleagues used transabdominal U/S to evaluate uterine thickness in
642 women at 36 to 38 weeks. The patients were divided into one of four groups,
according to myometrial thickness. The investigators correlated the measurements with
obstetric outcome and found that the thinner the myometrium, the greater the risk of
uterine dehiscence and rupture (Table 1).
14
At a cutoff of 3.5 mm, U/S had 88%
sensitivity for detection of uterine defects, 73.2% specificity, positive predictive value of 11.8%, and negative
predictive value of 99.3%.
14
Similarly, Gotoh and colleagues found evidence of uterine wall separation and only
visceral peritoneum covering the uterine contents at time of elective repeat cesarean in 91% of women whose
myometrial thickness was less than 2 mm in the second trimester.
12

Other investigators have used U/S to prospectively assess risk of uterine dehiscence and rupture. Asakura and
colleagues measured myometrial thickness at 37 to 40 weeks and evaluated the uterus at the time of repeat
cesarean or with internal examination after successful VBAC.
15
They defined dehiscence as separation of the
muscular layer with intact serosa or palpation of the serosa by vaginal examination without an intervening muscular
layer (confirmed by U/S). This study found no uterine ruptures. But with a cutoff of 1.6 mm, antepartum U/S had
sensitivity of 77.8% for uterine dehiscence, specificity of 88.6%, positive predictive value of 25.9%, and negative
predictive value of 98.7%.
16

How can we apply Asakura and colleagues' results to clinical practice? Their data on
U/S assessment of the uterine scar in the third trimester may help in the decision-
making process when weighing a trial of labor versus a repeat cesarean. The a priori
risk for intrapartum uterine rupture after one prior low-transverse cesarean delivery is
0.5% to 1.0%, which we generally accept as a reasonable risk when attempting a
vaginal delivery.
11
However, the risk rises to 25.9% when the thinnest part of the
lower-segment myometrium measured in a sagittal plane is less than 1.6 mm at 37 to
40 weeks. That is higher than the 5% to 9% risk of uterine rupture for labor with a prior
classic cesarean delivery, which is generally considered too high to consider a trial of
labor.
16
The bottom line: We need studies to determine if risk of intrapartum uterine
dehiscence or rupture is significantly reduced when the myometrium measures more
than 1.6 mm.
Both scarred and unscarred uteri progressively thin through the second and third
trimester, but scarred uteri seem to become significantly thinner. Furthermore, the degree of thinning appears to be
related to the risk for uterine dehiscence. In the future, evaluating the thickness of the uterine wall at term may be one
way to assess a woman's risk of intrapartum uterine dehiscence. And stratifying the risk may help clinicians counsel
patients about the decision to attempt VBAC. It should be noted, however, that as many as 25% of women at elective
repeat C/S may have an abnormally thinned lower uterine segment or occult dehiscence.
12,17

Uterine scars and abnormal placentation
Age, parity, and number of prior cesarean deliveries are all independent risk factors for placenta accreta.
3-5,18
Recent
data from the Maternal-Fetal Medicine Unit Network show that the risk of placenta accreta increases from 0.2% with
one prior C/S to 2.1% with four prior C/S and 6.7% with more than five prior C/S.
18
When placenta previa is also
present, however, the risk for accreta rises to 3.3%, 11%, 40%, and 61% with one, two, three, and four prior C/S
deliveries, respectively.
19
Therefore, evaluating abnormal placentation in women with a prior C/S delivery is an
important component of prenatal diagnosis.

Figure 2. Myometrial
thickness of term uterus
with history of cesarean
delivery.

Table 1. Correlation between
myometrial thickness and
uterine dehiscence
46


Both U/S and magnetic resonance imaging (MRI) have been used for
antepartum diagnosis of placenta accreta and increta.
20,21
They perform
equally well in identifying abnormal placentation, but MRI is better at
diagnosing posterior placenta accreta.
21,22
By comparison, U/S has been
shown to be 82.4% sensitive and 96.8% specific for diagnosis of placenta
accreta, with positive predictive value of 87.5% and negative predictive value
of 95.3%.
23
U/S with power Doppler can help delineate neovascularization,
potentially making possible diagnosis of placenta accreta as early as the first
trimester.
24,25
Some researchers have not been able to demonstrate increased
vascularity, but have instead relied on the gestational sac's position in the
endometrial cavity to indicate likelihood of placenta accreta later in pregnancy.
26

In the second and third trimester, sonography has become the diagnostic
standard for differentiating simple placenta previa from placenta previa
complicated by accreta. Comstock and colleagues reviewed all suspected and
confirmed cases of placenta accreta at their institution between 1990 and
2002 to determine which sonographic findings best correlated with placenta
accreta. They found that 54.5% of placenta accreta diagnoses were false
positive (sensitivity 85.7%, specificity 98.9%, positive predictive value 36.4%,
negative predictive value 99.9%), most of which were because the echolucent
area between the placenta and myometrium could not be seen.
27
The most
specific diagnostic criterion for placenta accreta was visualization of irregular
vascular spaces within the placenta (placental lacunae as originally described
by Guy and colleagues
28
), with sensitivity and specificity of 93%.
27
Figure 3
shows representative images of placenta accreta and Table 2 lists common sonographic findings.
It appears, then, that while both U/S and MRI can be used to diagnose placenta accreta, U/S is more attractive for
screening because it is cheaper and more readily available. Imaging is reasonably sensitive for diagnosis of placenta
accreta, but it reportedly produces high false-positive rates. Antepartum diagnosis of likely placenta accreta should
heighten your suspicion for accreta, although you still need to make the final diagnosis in the operating room.
Conclusion
Pregnancy after C/S continues to be an obstetric challenge. Assessing the uterine scar in women who have had a
C/S, before they become pregnant again, holds promise for determining risk of uterine dehiscence or rupture in the
next gestation. More research is needed, however, into clinical implications of sonographic findings before screening
can be integrated into risk assessment for uterine dehiscence and rupture.
U/S is also evolving as a tool for use in late pregnancy to assess risk of intrapartum uterine dehiscence and rupture.
Finally, U/S can also be used in assessment of abnormal placentation, which is an important component of
antepartum evaluation of a scarred uterus. Much remains to be learned about these new roles for U/S, but they have
potential to help patients and clinicians make more informed decisions about pregnancy after a C/S.
REFERENCES
1. National Center for Health Statistics. Health, United States, 2003. Hyattsville, MD: National Center for Health
Statistics, 2003.
2. Rosen MG, Dickinson JC. Vaginal birth after cesarean: a meta-analysis of indicators for success. Obstet Gynecol.
1990;76:865-869.
3. Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and
higher parity. Obstet Gynecol. 2002;99:976-980.
4. Clark Sl, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol.
1985;66:89-92.
5. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol.
1997;177:210-214.
6. Armstrong V, Hansen WF, Van Voorhis BJ, et al. Detection of cesarean scars by transvaginal ultrasound. Obstet
Gynecol. 2003;101:61-65.
7. Monteagudo A, Carreno C, Timor-Tritsch IE. Saline infusion sonohysterography in nonpregnant women with
previous cesarean delivery: the "niche" in the scar. J Ultrasound Med. 2001;20:1105-1115.
8. Regnard C, Nosbusch M, Fellemans C, et al. Cesarean section scar evaluation by saline contrast
sonohysterography. Ultrasound Obstet Gynecol. 2004;23:289-292.
9. Matsunaga JS, Daly CB, Bochner CJ, et al. Repair of uterine dehiscence with continuation of pregnancy. Obstet
Gynecol. 2004;104:1211-1212.
10. Klemm P, Koehler C, Mangler M, et al. Laparoscopic and vaginal repair of uterine scar dehiscence following
cesarean section as detected by ultrasound. J Perinat Med. 2005;33:324-331.
11. Lydon-Rochelle M, Holt Vl, Easterling TR, et al. Risk of uterine rupture during labor among women with a prior

Figure 3. Representative ultrasound
images of placenta accreta

Table 2. Sonographic findings in
placenta accreta
47


cesarean delivery. N Engl J Med. 2001;345:3-8.
12. Gotoh H, Masuzaki H, Yoshida A, et al. Predicting incomplete uterine rupture with vaginal sonography during the
late second trimester in women with prior cesarean. Obstet Gynecol. 2000;95:596-600.
13. Qureshi B, Inafuku K, Oshima K, et al. Ultrasonographic evaluation of lower uterine segment to predict the
integrity and quality of cesarean scar during pregnancy: a prospective study. Tohoku J Exp Med. 1997;183:55-65.
14. Rozenberg P, Goffinet F, Phillippe HJ, et al. Ultrasonographic measurement of lower uterine segment to assess
risk of defects of scarred uterus. Lancet. 1996;347:281-284.
15. Asakura H, Nakai A, Ishikawa G, et al. Prediction of uterine dehiscence by measuring lower uterine segment
thickness prior to the onset of labor: evaluation by transvaginal ultrasonography. J Nippon Med Sch. 2000;67:352-
356.
16. Scott JR. Avoiding labor problems during vaginal birth after cesarean delivery. Clin Obstet Gynecol. 1997;40:533-
541.
17. Michaels WH, Thompson HO, Boutt A, et al. Ultrasound diagnosis of defects in the scarred lower uterine segment
during pregnancy. Obstet Gynecol. 1988;71:112-120.
18. Chattopadhyay SK, Kharif H, Sherbeeni MM. Placenta praevia and accreta after previous caesarean section. Eur
J Obstet Gynecol Reprod Biol. 1993;52:151-156.
19. Silver RM. The MFMU cesarean section registry: maternal morbidity associated with multiple repeat cesarean
delivery. Am J Obstet Gynecol. 2004;191:S17. Abstract 37.
20. Kirkinen P, Helin-Martikainen Hl, Vanninen R, et al. Placenta accreta: imaging by gray-scale and contrast-
enhanced color Doppler sonography and magnetic resonance imaging. J Clin Ultrasound. 1998;26:90-94.
21. Lam G, Kuller J, McMahon M. Use of magnetic resonance imaging and ultrasound in the antenatal diagnosis of
placenta accreta. J Soc Gynecol Investig. 2002;9:37-40.
22. Levine D, Hulka Ca, Ludmir J, et al. Placenta accreta: evaluation with color Doppler US, power Doppler US, and
MR imaging. Radiology. 1997;205:773-776.
23. Chou MM, Ho ES, Lee YH. Prenatal diagnosis of placenta previa accreta by transabdominal color Doppler
ultrasound. Ultrasound Obstet Gynecol. 2000;15:28-35.
24. Chou MM, Tseng JJ, Ho ES, et al. Three-dimensional color power Doppler imaging in the assessment of utero-
placental neovascularization in placenta previa increta/percreta. Am J Obstet Gynecol. 2001;185:1257-1260.
25. Shih JC, Cheng WF, Shyu MK, et al. Power Doppler evidence of placenta accreta appearing in the first trimester.
Ultrasound Obstet Gynecol. 2002;19:623-625.
26. Comstock CH, Lee W, Vettraino IM, et al. The early sonographic appearance of placenta accreta. J Ultrasound
Med. 2003;22:19-23; quiz 24-6.
27. Comstock CH, Love JJ Jr., Bronstein RA, et al. Sonographic detection of placenta accreta in the second and third
trimesters of pregnancy. Am J Obstet Gynecol. 2004;190:1135-1140.
28. Guy GP, Peisner DB, Timor-Tritsch IE. Ultrasonographic evaluation of uteroplacental blood flow patterns of
abnormally located and adherent placentas. Am J Obstet Gynecol. 1990;163:723-727.



YXN0ZXJsaW5nI




Print Close Window


Note: Large images and tables on this page may necessitate printing in landscape mode.

Copyright 2007 The McGraw-Hill Companies. All rights reserved.

Williams Obstetrics > Section IV. Labor and Delivery > Chapter 26. Prior Cesarean
Delivery >

48



Prior Cesarean Delivery: Introduction
There are few issues in modern obstetrics that have been as controversial as the
management of the woman with a prior cesarean delivery. For many decades, a scarred
uterus was believed to contraindicate labor out of fear of uterine rupture. In 1916, Cragin
made his famous, oft-quoted, and now seemingly excessive pronouncement, "Once a
cesarean, always a cesarean." We must remember that when this statement was made, the
so-called classical vertical uterine incision was used almost universally. It was not until
1921 that the Kerr transverse incision was recommended. Among Cragin's contemporaries,
there were some who did not totally agree with his pronouncement. Writing in the fourth
edition of Williams Obstetrics, J. Whitridge Williams (1917) termed the statement "an
exaggeration." Now, 18 editions and nearly 90 years later, the controversy continues.
The year 1978 was another milestone in the history of prior cesarean delivery. Merrill and
Gibbs (1978) reported from the University of Texas at San Antonio that subsequent
vaginal delivery was safely attempted in 83 percent of their patients with prior cesarean
deliveries. This report served to rekindle interest in vaginal birth after prior cesarean at a
time when only 2 percent of American women who had previously undergone cesarean
birth were planning vaginal delivery. The report was timely because during this same
period, the rates of cesarean delivery in the United States were beginning to increase at an
unprecedented rate. Between 1980 and 1988, for example, the rate jumped from 17 to 25
percenta remarkable 50-percent increase in less than a decade. Meanwhile, evidence had
accrued that uterine rupture was infrequent and rarely catastrophic. Thus, in an effort to
address this escalation, the American College of Obstetricians and Gynecologists (1988)
recommended that, in the absence of a contraindication, a woman with one previous low-
transverse cesarean delivery be counseled to attempt labor in a subsequent pregnancy.
Accordingly, the frequency of vaginal birth after cesarean, commonly referred to as VBAC
and pronounced vee back, increased significantly in the United States. As shown in Figure
261, by 1996 almost 30 percent of women with a prior cesarean were being delivered
vaginally. In 1991, Dr. Roy Pitkin, former editor of Obstetrics & Gynecology, wrote that ".
. . without question, the most remarkable change in obstetric practice over the last decade
was management of the woman with prior cesarean delivery."
Figure 261.


Total and primary cesarean delivery rate and vaginal birth after previous cesarean
(VBAC) rate: United States, 19892002. (Reproduced from Hamilton and associates,
2003.)

Trial of Labor versus Repeat Cesarean Delivery
Risks and Benefits
Beginning in 1989, as the number of women with prior cesareans attempting vaginal
delivery increased, there were a number of reports from around the United States and
Canada that suggested that VBAC might be riskier than anticipated (Leveno, 1999). This
led Scott (1991) to suggest an "alternative viewpoint on mandatory trial of labor," based on
adverse experiences with 12 women in Utah who suffered uterine rupture during a trial of
labor. Two women required hysterectomy, there were three perinatal deaths, and two
infants suffered significant long-term neurological impairment. Porter and colleagues
(1998) subsequently reported that there were 26 uterine ruptures in Salt Lake City between
1990 and 1996 and that 23 percent of the infants were dead or damaged as a result of
intrapartum asphyxia. Reports such as these raised serious concern about the safety of this
practice and contributed to heightened controversy (Flamm, 1997). These concerns
resulted in fewer women with a prior cesarean incision attempting vaginal delivery, which
led to a corresponding increase in the overall cesarean delivery rate, again seen in Figure
49


261.
Magnitude of Risk
Although uterine rupture and its associated complications clearly are increased with a trial
of labor, some investigators have argued that these factors should weigh only minimally in
the decision to attempt VBAC because the absolute risk of these complications is quite
low. For example, Landon and collaborators (2004) from the MaternalFetal Medicine
Units (MFMU) Network compared the outcomes of nearly 18,000 women who attempted a
trial of labor with those of more than 15,000 women who were delivered by elective repeat
cesarean. As shown in Table 261, although the risk of uterine rupture was higher among
the women undergoing a trial of labor, the absolute risk was small. Specifically, the risk of
uterine rupture was 7 per 1000. In comparison, however, there were no uterine ruptures in
the elective cesarean delivery group. Moreover, the rates of stillbirth and hypoxic ischemic
encephalopathy were significantly greater in the trial of labor group.
Table 261. Complications Associated with a Trial of Labor in Women Delivered at an
NICHD MaternalFetal Medicine Units Network Center, 19992002

Complication Trial of Labor
Group n =
17,898 (%)
Elective Repeat
Cesarean Group n =
15,801 (%)
Odds Ratio (95%
Confidence
Interval)
P
value
Uterine rupture 124 (0.7) 0 N/A < .001
Uterine dehiscence 119 (0.7) 76 (0.5) 1.38 (1.041.85) .03
Hysterectomy 41 (0.2) 47 (0.3) 0.77 (0.511.17) .22
Thromboembolic
disease
7 (0.04) 10 (0.1) 0.62 (0.241.62) .32
Transfusion 304 (1.7) 158 (1.0) 1.71 (1.412.08) < .001
Uterine infection 517 (2.9) 285 (1.8) 1.62 (1.401.87) < .001
Maternal death 3 7 0.38 (0.101.46) .21
Antepartum
stillbirth
a



3738 weeks 18 (0.1) 8 (0.1) 2.93 (1.276.75) .008
39 weeks or more 16 (0.1) 5 (0.1) 2.70 (0.997.38) .07
Intrapartum
stillbirth
a



3738 weeks 1 0 N/A .43
39 weeks or more 1 0 N/A 1.00
Term HIE
a


13 (0.08) 0 N/A .0004
Term neonatal
death
a


13 (0.08) 7 (0.05) 1.82 (0.734.57) .19


HIE = hypoxic ischemic encephalopathy; N/A = not applicable, NICHD = National
Institutes of Child Health and Human Development.
a
Denominator is 15,338 for the trial of labor group and 15,014 for the elective repeat
cesarean delivery group.
50


From Landon and collaborators (2004), with permission.
Smith and associates (2002) measured the risks of intrapartum and neonatal death
associated with a trial of labor compared with those of a planned repeat cesarean delivery
using a database linking all maternity hospitals in Scotland. Their analysis involved
313,238 term singleton deliveries that were registered between 1992 and 1997 and
included 24,529 births from women with a prior cesarean delivery. The risk of delivery-
related perinatal death was approximately 1.3 per 1000 among the 15,515 women with a
prior cesarean who attempted a vaginal delivery. Although the absolute risk was again
small, this rate was 11 times greater than the risk of perinatal death associated with a
planned repeat cesarean.
The results of these and other investigations, including two large systematic reviews by
Chauhan and colleagues (2003) and Mozurkewich and Hutton (2000), are congruent.
Collectively, they suggest that the absolute risk of uterine rupture attributable to a trial of
labor resulting in death or injury to the fetus is about 1 per 1000. The major controversy
surrounding the management of women with a prior cesarean thus stems from the
question: Is a 1 per 1000 risk of having an otherwise healthy fetus die or be damaged as a
result of a trial of labor acceptable?
Maternal Morbidity
Another potential argument in support of VBAC has been that a trial of labor is associated
with reduced risks for the mother compared with those of a repeat cesarean delivery.
Maternal mortality does not appear to differ significantly between women undergoing a
trial of labor compared with that of an elective repeat cesarean (Landon and co-workers,
2004; Mozurkewich and Hutton, 2000). Estimates of maternal morbidity, however, have
produced conflicting results. In the meta-analysis by Mozurkewich and Hutton (2000),
women undergoing a trial of labor were about half as likely to require a blood transfusion
or hysterectomy compared with those undergoing an elective repeat cesarean delivery.
Conversely, in the MFMU Network study cited earlier, Landon and co-workers (2004)
observed that the risks of transfusion and infection were significantly greater for women
attempting a trial of labor (see Table 261). McMahon and associates (1996), in a
population-based study of 6138 women, found that major complicationshysterectomy,
uterine rupture, or operative injurywere almost twice as common in women undergoing
a trial of labor compared with those of those undergoing an elective second cesarean
delivery. Moreover, compared with a successful trial of labor, the risk of these major
complications was fivefold greater in women whose attempt at a vaginal delivery failed.
Costs
Analyses from Northwestern Hospital in Chicago support the safety of VBAC as well as
its cost effectiveness in women with one or two prior low-transverse uterine incisions
(Grobman and associates, 2000; Socol and Peaceman, 1999). By applying a mathematical
model to a hypothetical cohort of 100,000 pregnant women whose only prior delivery was
through a low-transverse cesarean incision, a policy of routine repeat cesarean for a second
birth was calculated to result in an increased cost of $179 million. Similarly, DiMaio and
colleagues (2002) estimated that total hospital costs for mother and newborn were nearly
$1100 higher for each elective repeat cesarean compared with that of those who attempted
vaginal delivery. Conversely, Clark and colleagues (2000) concluded that "when costs as
opposed to charges are considered and the cost of long-term care for neurologically injured
infants is taken into account, trial of labor after previous cesarean is unlikely to be
associated with a significant cost saving for the health care system."
Elective Repeat Cesarean Delivery
As described in Chapter 25 (see Patient Choice Cesarean Delivery), compared with vaginal
delivery, cesarean birth is associated with increased risks, including anesthesia,
hemorrhage, damage to the bladder and other organs, pelvic infection, scarring, and other
less frequent events. In spite of these potential concerns, an elective repeat cesarean is
51


considered by many women to be preferable to attempting a trial of labor. Frequent
reasons for this preference include the convenience of a scheduled delivery and the fear of
a prolonged and potentially dangerous labor. Abitbol and associates (1993) studied such
preferences by analyzing the results of a program in which women who were candidates
for a trial of labor were able to elect their route of delivery following extensive counseling.
Information was provided in three separate sessions concerning advantages and
disadvantages of VBAC and repeat cesarean delivery. Of the 312 women studied, 125 (40
percent) opted for a repeat cesarean. There were no complications in the elective cesarean
group compared with two unanticipated fetal deaths in the VBAC group. All women were
interviewed on the day of discharge regarding their delivery experience. Of the women
delivered by scheduled cesarean, 93 percent reported that they were satisfied with their
choice. This compared with only 53 percent of women who elected a trial of labor and 80
percent of those who had an uncomplicated trial of labor.
Fetal Maturity
If elective repeat cesarean delivery is planned, it is essential that the fetus be mature. The
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2002) have established guidelines for timing an elective operation.
According to these criteria, elective delivery may be considered and fetal maturity
assumed if at least one of the criteria outlined in Table 262 is met. In all other instances,
fetal pulmonary maturity must be documented by amnionic fluid analysis before elective
repeat cesarean is undertaken (see Chap. 29, Amniocentesis for Fetal Lung Maturity).
Alternatively, the onset of spontaneous labor is awaited.
Table 262. Establishment of Fetal Maturity Prior to Elective Repeat Cesarean Delivery

Fetal maturity may be assumed if one of the following criteria is met:
1. Fetal heart sounds have been documented for 20 weeks by nonelectronic fetoscope or
for 30 weeks by Doppler ultrasound
2. It has been 36 weeks since a positive serum or urine chorionic gonadotropin pregnancy
test was performed by a reliable laboratory
3. An ultrasound measurement of crown-rump length, obtained at 611 weeks, supports
current gestational age of 39 weeks or more
4. Clinical history and physical and ultrasound examination performed at 1220 weeks
support current gestational age of 39 weeks or more

From the American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2002), with permission.
Candidates for a Trial of Labor
As the foregoing discussion makes clear, a plurality of positions exists regarding the
optimal management of the woman with a prior cesarean delivery. Specifically, through
2003, more than 1000 citations were available in the literatureand no randomized
trialsaddressing subsequent attempts at vaginal delivery. In 1998 and 1999, the
American College of Obstetricians and Gynecologists issued updated practice bulletins
supporting VBAC but also urging a more cautious approach. In part, their recommendation
reads:
It has become apparent that VBAC is associated with a small but significant risk of uterine
rupture with poor outcomes for both mother and infant. . . . These developments, which
have led to a more circumspect approach to trial of labor by even the most ardent
supporters of VBAC, illustrate the need to reevaluate VBAC recommendations.
Several factors are pertinent to the evaluation of women for a trial of labor to attempt
VBAC. The most recent recommendations of the American College of Obstetricians and
52


Gynecologists (2004) for selecting appropriate candidates are listed in Table 263.
Summarized in the following sections are these and other considerations for the evaluation
and management of the woman with a prior cesarean delivery. Such evaluation is
particularly challenging given the lack of randomized studies. Indeed, based on their recent
review of 100 published studies, Hashima and co-workers (2004) concluded that little
high-quality data are available to guide clinical decisions regarding selection of women
who are likely to have a successful trial of labor. Following a review of more than 600
articles, Guise and colleagues (2004) reached a similar conclusion.
Table 263. Recommendations of the American College of Obstetricians and
Gynecologists Useful for Selection of Candidates for Vaginal Birth After Cesarean
Delivery (VBAC)

No more than 1 prior low-transverse cesarean delivery
Clinically adequate pelvis
No other uterine scars or previous rupture
Physician immediately available throughout active labor who is capable of
monitoring labor and performing emergency cesarean delivery
Availability of anesthesia and personnel for emergency cesarean delivery


From the American College of Obstetricians and Gynecologists (2004), with permission.
Type of Prior Uterine Incision
Women with a transverse scar confined to the lower uterine segment have the lowest risk
of symptomatic scar separation during a subsequent pregnancy (Table 264). The highest
rates of rupture have been reported for incisions extending into the fundusthe classical
incision (Fig. 262). Importantly, in about one third of women, the classical scar will
rupture before the onset of labor. Not infrequently, rupture may take place several weeks
before term. In a review of 157 women with a prior classical cesarean, Chauhan and
colleagues (2002) reported that one woman had a complete uterine rupture prior to the
onset of labor and 15 (9 percent) others suffered a uterine dehiscence (see Uterine
Rupture). Similarly, we have encountered a term abdominal pregnancy in a woman whose
prior classical incision had separated weeks to months before she was delivered by repeat
cesarean.
Table 264. Estimated Risks for Uterine Rupture in Women with a Prior Cesarean
Delivery

Prior Uterine Incision Estimated Rupture (%)
Classical 49
-shaped 49
Low-vertical 17
Low-transverse 0.21.5

From the American College of Obstetricians and Gynecologists (1999), with permission.
Figure 262.


53


Ruptured vertical cesarean section scar (arrow) identified at time of repeat cesarean
delivery early in labor; asterisks indicate some of the sites of densely adherent omentum.
In women with uterine malformations who have undergone cesarean delivery, the risks for
uterine rupture in a subsequent pregnancy may be as high as with a classical incision.
Specifically, Ravasia and associates (1999) reported the risk of subsequent rupture to be 8
percent in women with unicornuate, bicornuate, didelphic, and septate uterine
malformations (see Chap. 40, Uterine Malformations).
The risk of uterine rupture in women with a prior vertical incision that did not extend into
the fundus is controversial. Martin and co-authors (1997) and Shipp and colleagues (1999)
reported that these low-vertical uterine incisions did not have an increased risk for rupture
when compared with that of low-transverse incisions. The American College of
Obstetricians and Gynecologists (2004) concluded that, although there is limited evidence,
women with a prior vertical incision in the lower uterine segment without fundal extension
may be candidates for VBAC. This is in contrast to prior classical or T-shaped uterine
incisions, which are considered contraindications to VBAC. It seems reasonable to us that,
given the very few conditions that call for vertical incisionsfor example, preterm
delivery with a poorly developed lower uterine segmentthese incisions almost invariably
extended into the active segment. The unanswered question is: How far upward does the
incision have to extend before the risk of rupture is equivalent to a true classical incision?
Thus, when preparing an operative report following a vertical uterine incision, it is
essential to document its exact extent in a manner that cannot be misunderstood by
subsequent surgeons.
Women who have previously sustained a uterine rupture are at increased risk for
recurrence. Those with a rupture confined to the lower segment have been reported to have
a 6-percent recurrence risk in subsequent labor, whereas those whose prior rupture
included the upper uterus have a 32-percent recurrence risk (Reyes-Ceja and associates,
1969; Ritchie, 1971). We are of the view that women with prior uterine ruptures or
classical or -shaped incisions ideally are delivered by cesarean on achievement of fetal
pulmonary maturity and prior to the onset of labor, and that such women should be warned
of the hazards of unattended labor and signs of possible uterine rupture.
Closure of Prior Incision
As discussed in Chapter 25 (see Repair of the Uterus), the low-transverse uterine incision
typically is closed in one or two layers. Whether the risk of subsequent uterine rupture is
related to the number of layers is controversial. Chapman (1997) and Tucker (1993) and
their associates found no relationship between a one- and two-layer closure and risk of
subsequent uterine rupture. Although Durnwald and Mercer (2003) also found no
increased risk of rupture, uterine dehiscence was more common after single-layer closure.
In contrast, Bujold and co-workers (2002) reviewed the operative records of 1980 women
who underwent a trial of labor, including 23 (1.2 percent) who experienced uterine rupture.
They found that a single-layer closure was associated with nearly a fourfold increased risk
of rupture compared with a double-layer closure. The latter consisted of a running-lock
suture followed by a running, nonlocking imbricating suture. In response, Vidaeff and
Lucas (2003) argued that experimental models of wound healing have not demonstrated
any advantages with a double-layer closure. Because of potentially confounding variables
inherent in this type of retrospective study, they concluded that the evidence is insufficient
to routinely recommend a double-layer closure. There should be further study of the
relationship between closure technique and subsequent uterine rupture. This is especially
true given the limited available information regarding healing and scarring of cesarean
incisions.
Healing of the Cesarean Incision
Williams (1921) believed that the uterus heals by regeneration of the muscular fibers and
not by development of scar tissue. Certainly, upon inspection of the unopened uterus at
repeat cesarean delivery, there is usually no trace of the former incision, or at most, an
54


almost invisible linear scar. Also, when the uterus is removed and fixed in formalin, there
often is no visible scar, or only a shallow vertical furrow in the external and internal
surfaces of the anterior uterine wall is seen, with no trace of scar tissue between them.
On the other hand, Schwarz and co-workers (1938) concluded that healing was mainly by
fibroblast proliferation. They studied the uterine incision site some days after cesarean
incision and observed that as the scar shrinks, connective tissue proliferation becomes less
obvious. If the cut surfaces of the uterus are closely apposed, the proliferation of
connective tissue is minimal, and the normal relation of smooth muscle to connective
tissue gradually is reestablished. Even when the healing is so poor that marked thinning
has resulted, the remaining tissue often is entirely muscular.
Interdelivery Interval
It seems logical to assume that the risk of uterine rupture would be increased if the
hysterotomy scar did not have sufficient time to heal. Studies of uterine scar healing using
magnetic resonance imaging suggest that complete uterine involution and restoration of
anatomy may require at least 6 months (Dicle and colleagues, 1997). To explore this issue
further, Shipp and associates (2001) retrospectively examined the relationship between
interdelivery interval and uterine rupture in 2409 women with one prior cesarean delivery.
There were 29 (1.4 percent) cases of uterine rupture. They found that interdelivery
intervals of 18 months or less were associated with a threefold increased risk of
symptomatic uterine rupture compared with that of those over 18 months.
Number of Prior Cesarean Incisions
The risk of uterine rupture increases with the number of previous cesarean deliveries.
Miller and colleagues (1994) studied 12,707 women undergoing a trial of labor after
cesarean delivery. They reported rupture rates of 0.6 percent and 1.8 percent for women
with one and two prior cesarean deliveries, respectively. Similarly, in the MFMU Network
study by Landon and co-investigators (2004a), uterine rupture was twice as high in women
with multiple prior cesareans compared with that of those with only one1.4 versus 0.7
percent. Caughey and colleagues (1999) compared uterine rupture rates in 3757 women
with one prior cesarean delivery with those of 134 women who had two prior cesarean
incisions. Although women with a classical incision usually were delivered by elective
repeat cesarean, the type of prior uterine incision was not specified. The rate of uterine
rupture was increased nearly fivefold in women with two previous cesarean deliveries
compared with that of those only with one3.7 versus 0.8 percent.
Any previous vaginal delivery, either before or following a cesarean birth, significantly
improves the prognosis for a subsequent successful VBAC, with either spontaneous or
induced labor (Caughey and colleagues, 1998; Grinstead and Grobman, 2004; Hendler and
co-workers, 2004). Prior vaginal delivery also lowers the risk of subsequent uterine rupture
(Zelop and associates, 2000). Indeed, the most favorable prognostic factor is prior vaginal
delivery. The American College of Obstetricians and Gynecologists (2004) has recently
taken the position that for women with two prior low-transverse cesarean deliveries, only
those with a prior vaginal delivery should be considered for VBAC.
Indication for Prior Cesarean Delivery
The success rate for a trial of labor depends to some extent on the indication for the
previous cesarean delivery. Generally, about 60 to 80 percent of trials of labor after prior
cesarean birth result in vaginal delivery (American College of Obstetricians and
Gynecologists, 2004). In a large series reported by Wing and Paul (1999), 91 percent of
women whose first cesarean was for breech presentation had a successful VBAC. When
fetal distress was the original indication, the success rate was 84 percent. In those with
dystocia as the original indication, Impey and O'Herlihy (1998) reported that even when
the strictest criteria are used to diagnose dystocia, a VBAC rate of 68 percent can be
achieved.
55


Hoskins and Gomez (1997) analyzed VBAC success rates in 1917 women in relation to
cervical dilation achieved before the original cesarean delivery was performed for
dystocia. For women whose cesarean was performed at 5 cm or less, the VBAC success
rate was 67 percent. It was 73 percent when the cervix was dilated 6 to 9 cm. The success
rate of vaginal delivery fell to 13 percent when dystocia was diagnosed during the second
stage. These latter findings seem counterintuitive and, indeed, Bujold and Gauthier (2001)
reported a 75-percent VBAC success rate in women who had undergone a prior cesarean
for second-stage dystocia.
Fetal Macrosomia
It would seem that increasing fetal size would increase the risk of uterine rupture with
VBAC. This, however, remains unproven. Zelop and associates (2001) compared the
outcomes of 2749 women undergoing a trial of labor at term. There were 29 (1.1 percent)
uterine ruptures. Although not statistically significant, the rate of uterine rupture for
women whose infants weighed at least 4000 g was 1.6 percent compared with that of 1.0
percent for those whose infants weighed less. The rate of uterine rupture was even greater
(2.4 percent) when the birthweight exceeded 4250 g. Similarly, Elkousy and colleagues
(2003) found that for women attempting VBAC who had no previous vaginal deliveries,
the relative risk of uterine rupture more than doubled when the birthweight was at least
4000 g.
Maternal Obesity
Carroll and colleagues (2003) found that as maternal weight increased, the rate of VBAC
success decreased. In their study, only 4 of 30 women (13 percent) undergoing a trial of
labor who weighed more than 300 pounds delivered vaginally. Their observations that
puerperal infection was higher in obese women attempting a trial of labor was confirmed
by Edwards and associates (2003). Maternal obesity is detailed in Chapter 43.
Labor and Delivery Considerations
The American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2002) have formulated the following guidelines for women with a prior
cesarean who have chosen a trial of labor:
1. Prompt evaluation of the laboring patient must be performed.
2. Continuous electronic monitoring of fetal heart rate and uterine contractions should
be considered (see Chap. 18, Electronic Fetal Monitoring).
3. Personnel familiar with the potential complications of a trial of labor should be
vigilant for nonreassuring fetal heart rate patterns and inadequate progress of labor.
4. Attempts should be limited to institutions with physicians immediately available to
provide emergency care.
Lavin and co-workers (2002) surveyed all hospitals in Ohio to determine the number that
actually had an obstetrician, anesthesia coverage, and a surgical team immediately
availabledefined as present in the hospitalwhen a woman was attempting a trial of
labor. A complete complement was available in 15, 63, and 100 percent of level I, II, and
III institutions, respectively. Because VBAC deliveries were equally distributed among the
institutions, the investigators concluded that many women may be attempting VBAC
under less than optimal conditions. They recommended that there is a need to examine
staffing and referral patterns.
Informed Consent
No woman should be mandated to undergo a trial of labor. Instead, the risks and benefits
of a trial of labor versus a repeat cesarean delivery should be discussed with any woman
with a prior uterine incision. The ultimate decision to attempt a vaginal delivery should be
made by the informed patient and her physician. The American Academy of Pediatrics and
the American College of Obstetricians and Gynecologists (2002) recommend that the
56


following issues be addressed:
1. Advantages of a successful vaginal delivery, for example, shorter postpartum
hospital stay; less painful, more rapid recovery; and others.
2. Contraindications to a trial of labor, for example, prior classical cesarean, placenta
previa, and others.
3. Risk of uterine rupture (approximately 1 percent).
4. Increased risk of uterine rupture with more than one prior cesarean delivery,
attempts at cervical ripening or labor induction, macrosomia, and oxytocin
augmentation.
5. In the event of rupture, there is a 10- to 25-percent risk of significant adverse fetal
sequelae.
6. Although catastrophic uterine rupture leading to perinatal death or permanent
neonatal injury is rare, occurring less often than 1 per 1000 VBAC attempts, it does
occur despite the best available resources.
Cervical Ripening and Labor Stimulation
Any attempt to induce cervical ripening or to induce or augment labor increases the risk of
uterine rupture in women undergoing a trial of labor.
Oxytocin
Use of oxytocin to induce or augment labor has been implicated in uterine ruptures in
women attempting VBAC. Turner (1997) observed that 13 of the 15 uterine ruptures
reported at the Coombe Hospital in Dublin between 1982 and 1991 occurred in women
with prior cesareans who had been given an oxytoxic agent, usually for induction of labor.
In contrast, cautious use of intravenous oxytocin to augment labor in women with prior
cesarean at this hospital was rarely associated with uterine rupture.
Zelop and associates (1999) analyzed uterine ruptures at Brigham and Women's Hospital
after induced or augmented labor in women with one prior cesarean delivery. Rupture
occurred in 2.3 percent of those induced compared with 1 and 0.4 percent of those whose
labor was augmented or was spontaneous, respectively. They urged caution when using
oxytocin for labor stimulation in these women. Goetzl and associates (2001) examined the
relationship between the total oxytocin dose and duration of induction and the risk of
uterine rupture. Although not significant, oxytocin dose and duration correlated directly
with uterine rupture. The investigators concluded, however, that the differences in the dose
or patterns of oxytocin use were not substantial enough to develop safer induction
protocols.
The American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2002) have concluded that oxytocin may be used for both labor induction
and augmentation with close patient monitoring in women with a prior cesarean delivery
undergoing a trial of labor (see Chap. 22, Labor Induction and Augmentation with
Oxytocin).
Experiences at Parkland Hospital
Our experience with uterine ruptures led us to the decision to discontinue the use of
oxytocin in women with prior cesarean deliveries. Between 1986 and 1990, a trial of labor
was undertaken by 2044 of the 7049 women with prior cesarean deliveries. Of these
women, 1482 (73 percent) delivered vaginally. Uterine rupture with part of the fetus
extruded outside of the uterus occurred in three women, for a rate of 1.5 per 1000. In
another 307 women who received oxytocin during their trial of labor, three uterine
ruptures (10 per 1000) occurred. These events prompted a reappraisal of our use of
oxytocin and the adoption of a more conservative approach.
Prostaglandins
57


Several prostaglandin preparations commonly are employed for cervical ripening or labor
induction. Recent evidence indicates that their use in women attempting VBAC
substantively increases the risk of uterine rupture. For example, Ravasia and colleagues
(2000) compared the rupture rates between 172 such women given prostaglandin E
2
gel
and 1544 similar women in spontaneous labor. The rate of uterine rupture was
significantly greater in the women treated with prostaglandin E
2
gel than in those having
spontaneous labor2.9 percent versus 0.5 percent.
There are only a few reports describing the use of the prostaglandin E
1
analogue
misoprostol in women with a prior cesarean delivery. Wing and colleagues (1998)
prematurely terminated their randomized study of oxytocin versus misoprostol for labor
induction in women with previous cesarean delivery after 2 of the first 17 women
randomized to misoprostol experienced a uterine rupture. Sciscione and co-workers (1998)
described a case of uterine rupture following misoprostol administration in a woman
attempting VBAC. The editors of the Australian and New Zealand Journal of Obstetrics
and Gynaecology published the report for the stated purpose of warning other investigators
of the potential hazards of studying misoprostol in women with a prior cesarean delivery.
Lydon-Rochelle and associates (2001) performed a retrospective, population-based study
in Washington State from 1987 through 1996. They included all primiparous women who
delivered a live singleton infant by cesarean and who also delivered a second child during
the study period. Of the 20,095 women included, 13,115 (65 percent) underwent a trial of
labor. As shown in Table 265, the risk of uterine rupture was nearly 16-fold greater for
women undergoing induction of labor with prostaglandins compared with that of a
repeated cesarean delivery without labor. Based in large part on the results of this study,
the American College of Obstetricians and Gynecologists (2002, 2004) discourage the use
of prostaglandin cervical ripening agents for the induction of labor in these women. They
further recommend that if induction of labor in a woman with a prior cesarean delivery is
necessary for a clear and compelling clinical indication, the potential increased risk of
uterine rupture with prostaglandin use should be discussed with the patient and
documented.
Table 265. Incidence and Relative Risk of Uterine Rupture During a Second Delivery
Among Women with a Prior Cesarean Delivery

Mode of Second Delivery No. of
Women
Incidence of
Rupture (per 1000)
a


Relative Risk (95%
Confidence Interval)
Repeat cesarean delivery
without labor
6,980 1.6 1.0
Spontaneous onset of
labor
10,789 5.2 3.3 (1.86.0)
Induction of labor without
prostaglandins
1,960 7.7 4.9 (2.49.7)
Induction of labor with
prostaglandins
366 24.5 15.6 (8.130.0)


a
Incidence is expressed as the number of cases of uterine rupture per 1000 women who
delivered a singleton infant after a prior cesarean delivery. Women who had repeated
cesarean delivery without labor served as the referent group.
Reproduced from Lydon-Rochelle and associates (2001), with permission.
As also shown in Table 265, Lydon-Rochelle and colleagues (2001) found a threefold
risk of uterine rupture associated with spontaneous labor alone compared with the risk
associated with elective repeat cesarean delivery. Based on these findings, Greene (2001)
58


editorialized that elective repeat cesarean is the safest route of delivery for the infant.
Epidural Analgesia
The use of epidural analgesia for labor in women with a prior cesarean delivery was
debated in the past because it was thought that such a technique might mask the pain of
uterine rupture. As evidence accrued, however, it was found that less than 10 percent of
women with scar separation experience pain and bleeding. Instead, fetal heart rate
decelerations are the most likely sign of rupture (Flamm and associates, 1990). Several
studies attest to the safety of properly conducted epidural analgesia for labor (Farmer and
colleagues, 1991; Flamm and associates, 1994). Moreover, vaginal delivery rates are
similar among women who receive an epidural for labor compared with those who do not
(Flamm and co-workers, 1988; Stovall and colleagues, 1987). The American Academy of
Pediatrics and the American College of Obstetricians and Gynecologists (2002) have
concluded that epidural analgesia may safely be used during a trial of labor. They further
recommend that the anesthesia service be notified whenever a woman with a prior
cesarean is admitted in active labor.
Uterine Scar Exploration
Although some obstetricians routinely document the integrity of the old scar by palpation
following successful vaginal delivery, such uterine exploration is felt by others to be
unnecessary. Currently, it is not known what effect documentation of an asymptomatic
scar has on subsequent reproduction or route of delivery. There is general agreement,
however, that surgical correction of a scar dehiscence is necessary only if significant
bleeding is encountered. Asymptomatic separations do not generally require exploratory
laparotomy and repair.
External Cephalic Version
Limited data suggest that external cephalic version for breech presentation may be as
successful for women with a prior cesarean as for women without such a history
(American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists, 2002). Breech presentation and external cephalic version are addressed in
Chapter 24 (see Version).
Uterine Rupture
Classification
Uterine rupture typically is classified as either complete (all layers of the uterine wall
separated) or incomplete (uterine muscle separated but visceral peritoneum is intact).
Incomplete rupture is also commonly referred to as uterine dehiscence. As expected,
morbidity and mortality are appreciably greater when rupture is complete. Currently, the
greatest risk factor for either complete or incomplete uterine rupture is prior cesarean
delivery. Indeed, in a review of all cases of uterine rupture in Nova Scotia between 1988
and 1997, Kieser and Baskett (2002) reported that 92 percent occurred in women with a
prior cesarean birth. Other causes of uterine rupture are discussed in Chapter 35 (see
Rupture of the Uterus).
Diagnosis
Prior to circulatory collapse from hemorrhage, the symptoms and physical findings may
appear bizarre unless the possibility of uterine rupture is kept in mind. For example,
hemoperitoneum from a ruptured uterus may result in irritation of the diaphragm with pain
referred to the chestleading one to the diagnosis of pulmonary or amnionic fluid
embolism instead of uterine rupture. Few women experience cessation of contractions
following uterine rupture, and the use of intrauterine pressure catheters has not been shown
to assist reliably in the diagnosis (Rodriguez and associates, 1989). Instead, the most
common electronic fetal monitoring finding tends to be sudden, severe heart rate
decelerations that may evolve into late decelerations, bradycardia, and undetectable fetal
59


heart action (American Academy of Pediatrics and American College of Obstetricians and
Gynecologists, 2002). In the Nova Scotia study cited earlier, 57 percent of the diagnoses
were based primarily on fetal heart rate abnormalities (Kieser and Baskett, 2002). Finally,
in a recent comparison of fetal heart rate characteristics in 36 cases of uterine rupture
versus 100 matched controls, Ridgeway and co-workers (2004) found that bradycardia was
the only finding that differentiated uterine rupture from a successful trial of labor.
In a minority of women, the appearance of uterine rupture is identical to that of placental
abruption. In most, however, there is remarkably little appreciable pain or tenderness.
Also, because most women in labor are treated for discomfort with either narcotics or
lumbar epidural analgesia, pain and tenderness may not be readily apparent. The condition
usually becomes evident because of signs of fetal distress and occasionally because of
maternal hypovolemia from concealed hemorrhage.
In some cases in which the fetal presenting part has entered the pelvis with labor, loss of
station may be detected by pelvic examination. If the fetus is partly or totally extruded
from the site of uterine rupture, abdominal palpation or vaginal examination may be
helpful to identify the presenting part, which will have moved away from the pelvic inlet.
A firm contracted uterus may at times be felt alongside the fetus.
Prognosis
With rupture and expulsion of the fetus into the peritoneal cavity, the chances for intact
fetal survival are dismal, and reported mortality rates range from 50 to 75 percent. Fetal
condition depends on how much placenta is intact, although this likely decreases over
minutes. If the fetus is alive at the time of rupture, the only chance of continued survival is
afforded by immediate delivery, most often by laparotomy. Otherwise, hypoxia from both
placental separation and maternal hypovolemia is inevitable. If rupture is followed by total
placental separation, then very few infants will be salvaged.
The maternal prognosis is much better and rupture is seldom fatal. If untreated, however,
most women would die from hemorrhage or, less often, later from infection.
Hysterectomy Versus Repair
In cases of scar separation without bleeding following VBAC, exploratory laparotomy is
not indicated. With frank rupture during a trial of labor, however, hysterectomy may be
required. In two reports by McMahon (1996) and Miller (1997) and their colleagues, 10 to
20 percent of such women required hysterectomy for hemostasis. In selected cases, suture
repair with uterine preservation may be performed. Sheth (1968) described outcomes from
a series of 66 women in whom repair of a uterine rupture was elected rather than
hysterectomy. In 25 instances, the repair was accompanied by tubal sterilization. Thirteen
of the 41 mothers who did not have tubal sterilization had a total of 21 subsequent
pregnancies, and uterine rupture recurred in four instances. Hysterectomy is described in
Chapter 25 (see Peripartum Hysterectomy), and other techniques to control obstetrical
hemorrhage are detailed in Chapter 35.
References
Abitbol MM, Castillo I, Taylor UB, et al: Vaginal birth after cesarean section: The
patient's point of view. Am Fam Physician 47:129, 1993 [PMID: 8418576]
American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists: Guidelines for Perinatal Care, 5th ed. Elk Grove, Ill, American Academy
of Pediatrics, 2002
American College of Obstetricians and Gynecologists: Induction of labor for vaginal birth
after cesarean delivery. Committee Opinion No. 271, April 2002
American College of Obstetricians and Gynecologists: Vaginal birth after previous
cesarean delivery. Practice Bulletin No. 54, July 2004
60


American College of Obstetricians and Gynecologists: Vaginal birth after previous
cesarean delivery. Practice Bulletin No. 2, October 1998
American College of Obstetricians and Gynecologists: Guidelines for vaginal delivery
after a previous cesarean birth. Committee Opinion No. 64, October 1988
Bujold E, Bujold C, Hamilton EF, et al: The impact of a single-layer or double-layer
closure on uterine rupture. Am J Obstet Gynecol 186:1326, 2002 [PMID: 12066117]
Bujold E, Gauthier RJ: Should we allow a trial of labor after a previous cesarean for
dystocia in the second stage of labor? Obstet Gynecol 98:652, 2001 [PMID: 11576583]
Carroll CS, Magann EF, Chauhan SP, et al: Vaginal birth after cesarean section versus
elective repeat cesarean delivery: Weight-based outcomes. Am J Obstet Gynecol
188:1516, 2003 [PMID: 12824987]
Caughey AB, Shipp TD, Repke JT, et al: Rate of uterine rupture during a trial of labor in
women with one or two prior cesarean deliveries. Am J Obstet Gynecol 181:872, 1999
[PMID: 10521745]
Caughey AB, Shipp TD, Repke JT, et al: Trial of labor after cesarean delivery: The effect
of previous vaginal delivery. Am J Obstet Gynecol 179:938, 1998 [PMID: 9790374]
Chapman SJ, Owen J, Hauth JC: One- versus two-layer closure of a low transverse
cesarean: The next pregnancy. Obstet Gynecol 89:16, 1997 [PMID: 8990429]
Chauhan SP, Magann EF, Wiggs CD, et al: Pregnancy after classic cesarean delivery.
Obstet Gynecol 100:946, 2002 [PMID: 12423858]
Chauhan SP, Martin JN Jr, Henrichs CE, et al: Maternal and perinatal complications with
uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A
review of the literature. Am J Obstet Gynecol 189:408, 2003 [PMID: 14520209]
Clark SL, Scott JR, Porter TF, et al: Is vaginal birth after cesarean less expensive than
repeat cesarean delivery? Am J Obstet Gynecol 182:599, 2000 [PMID: 10739514]
Cragin E: Conservatism in obstetrics. N Y Med J 104:1, 1916
Dicle O, Kckler C, Pirnar T: Magnetic resonance imaging evaluation of incision healing
after cesarean sections. Eur Radiol 7:31, 1997 [PMID: 9000391]
DiMaio H, Edwards RK, Euliano TY, et al: Vaginal birth after cesarean delivery: An
historic cohort cost analysis. Am J Obstet Gynecol 186:890, 2002 [PMID: 12015504]
Durnwald C, Mercer B: Uterine rupture, perioperative and perinatal morbidity after single-
layer and double-layer closure at cesarean delivery. Am J Obstet Gynecol 189:925, 2003
[PMID: 14586327]
Edwards RK, Harnsberger DS, Johnson IM, et al: Deciding on route of delivery for obese
women with a prior cesarean delivery. Am J Obstet Gynecol 189:385, 2003 [PMID:
14520202]
Elkousy MA, Sammel M, Stevens E, et al: The effect of birth weight on vaginal birth after
cesarean delivery success rates. Am J Obstet Gynecol 188:824, 2003 [PMID: 12634665]
Farmer RM, Kirschbaum T, Potter D, et al: Uterine rupture during trial of labor after
previous cesarean section. Am J Obstet Gynecol 165:996, 1991 [PMID: 1951569]
Flamm BL: Once a cesarean, always a controversy. Obstet Gynecol 90:312, 1997 [PMID:
9241315]
Flamm BL, Goings JR, Liu Y, et al: Elective repeat cesarean delivery versus trial of labor:
61


A prospective multicenter study. Obstet Gynecol 83:927, 1994 [PMID: 8190433]
Flamm BL, Lim OW, Jones C, et al: Vaginal birth after cesarean section: Results of a
multicenter study. Am J Obstet Gynecol 158:1079, 1988 [PMID: 3369487]
Flamm BL, Newman LA, Thomas SJ, et al: Vaginal birth after cesarean delivery: Results
of a 5-year multicenter collaborative study. Obstet Gynecol 76:750, 1990 [PMID:
2216218]
Goetzl L, Shipp TD, Cohen A, et al: Oxytocin dose and the risk of uterine rupture in trial
of labor after cesarean. Obstet Gynecol 97:381, 2001 [PMID: 11239641]
Greene MF: Vaginal delivery after cesarean sectionis the risk acceptable? N Engl J Med
345:54, 2001 [PMID: 11439949]
Grinstead J, Grobman WA: Induction of labor after one prior cesarean: Predictors of
vaginal delivery. Obstet Gynecol 103:534, 2004 [PMID: 14990418]
Grobman WA, Peaceman AM, Socol ML: Cost-effectiveness of elective cesarean delivery
after one prior low transverse cesarean. Obstet Gynecol 95:745, 2000 [PMID: 10775741]
Guise J-M, Berlin M, McDonagh M, et al: Safety of vaginal birth after cesarean: A
systematic review. Obstet Gynecol 103:420, 2004 [PMID: 14990401]
Hamilton BE, Martin JA, Sutton PD: Births: Preliminary data for 2002. National Vital
Statistics Reports, Vol 51, No. 11. Hyattsville, Md: National Center for Health Statistics,
2003
Hashima JN, Eden KB, Osterweil P, et al: Predicting vaginal birth after cesarean delivery:
A review of prognostic factors and screening tools. Am J Obstet Gynecol 190:547, 2004
[PMID: 14981405]
Hendler I, Gauthier RJ, Bujold E: The effects of prior vaginal delivery compared to prior
VBAC on the outcomes of current trial of VBAC [abstract 384]. J Soc Gynecol Investig
11:202A, 2004
Hoskins IA, Gomez JL: Correlation between maximum cervical dilatation at cesarean
delivery and subsequent vaginal birth after cesarean delivery. Obstet Gynecol 89:591,
1997 [PMID: 9083318]
Impey L, O'Herlihy C: First delivery after cesarean delivery for strictly defined
cephalopelvic disproportion. Obstet Gynecol 92:799, 1998 [PMID: 9794672]
Kieser KE, Baskett TF: A 10-year population-based study of uterine rupture. Obstet
Gynecol 100:749, 2002 [PMID: 12383544]
Landon MB, Hauth JC, Leveno KJ, et al: Maternal and perinatal outcomes associated with
a trial of labor after prior cesarean delivery. N Engl J Med 351:25, 2004
Lavin JP, DiPasquale L, Crane S, et al: A state-wide assessment of the obstetric,
anesthesia, and operative team personnel who are available to manage the labors and
deliveries and to treat the complications of women who attempt vaginal birth after
cesarean delivery. Am J Obstet Gynecol 187:611, 2002 [PMID: 12237636]
Leveno KJ: Controversies in OB-Gyn: Should we rethink the criteria for VBAC? Contemp
Ob/Gyn, January 1999
Lydon-Rochelle M, Holt VL, Easterling TR, et al: Risk of uterine rupture during labor
among women with a prior cesarean delivery. N Engl J Med 345:3, 2001 [PMID:
11439945]
Martin JN, Perry KG, Roberts WE, et al: The care for trial of labor in the patients with a
prior low-segment vertical cesarean incision. Am J Obstet Gynecol 177:144, 1997 [PMID:
62


9240598]
McMahon MJ, Luther ER, Bowes WA Jr, et al: Comparison of a trial of labor with an
elective second cesarean section. N Engl J Med 335:689, 1996 [PMID: 8703167]
Merrill BS, Gibbs CE: Planned vaginal delivery following cesarean section. Obstet
Gynecol 52:50, 1978 [PMID: 683630]
Miller DA, Diaz FG, Paul RH: Vaginal birth after cesarean: A 10-year experience. Obstet
Gynecol 84:255, 1994 [PMID: 8041542]
Miller DA, Goodwin TM, Gherman RB, et al: Intrapartum rupture of the unscarred uterus.
Obstet Gynecol 89:671, 1997 [PMID: 9166298]
Mozurkewich EL, Hutton EK: Elective repeat cesarean delivery versus trial of labor: A
meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol 183:1187, 2000
[PMID: 11084565]
Pitkin RM: Once a cesarean? Obstet Gynecol 77:939, 1991 [PMID: 2030873]
Porter TF, Clark SL, Esplin MS, et al: Timing of delivery and neonatal outcomes in
patients with clinically overt uterine rupture during VBAC [abstract 73]. Am J Obstet
Gynecol 178:S31, 1998
Ravasia DJ, Brain PH, Pollard JK: Incidence of uterine rupture among women with
mullerian duct anomalies who attempt vaginal birth after cesarean delivery. Am J Obstet
Gynecol 181:877, 1999 [PMID: 10521746]
Ravasia DJ, Wood SL, Pollard JK: Uterine rupture during induced trial of labor among
women with previous cesarean delivery. Am J Obstet Gynecol 183:1176, 2000 [PMID:
11084562]
Reyes-Ceja L, Cabrera R, Insfran E, et al: Pregnancy following previous uterine rupture:
Study of 19 patients. Obstet Gynecol 34:387, 1969 [PMID: 5805538]
Ridgeway JJ, Weyrich DL, Benedetti TJ: Fetal heart rate changes associated with uterine
rupture. Obstet Gynecol 103:506, 2004 [PMID: 14990414]
Ritchie EH: Pregnancy after rupture of the pregnant uterus: A report of 36 pregnancies and
a study of cases reported since 1932. J Obstet Gynaecol Br Commonw 78:642, 1971
[PMID: 5558856]
Rodriguez MH, Masaki DI, Phelan JP, et al: Uterine rupture: Are intrauterine pressure
catheters useful in the diagnosis? Am J Obstet Gynecol 161:666, 1989 [PMID: 2782349]
Schwarz O, Paddock R, Bortnick AR: The cesarean scar: An experimental study. Am J
Obstet Gynecol 36:962, 1938
Sciscione AC, Nguyen L, Manley JS, et al: Uterine rupture during preinduction cervical
ripening with misoprostol in a patient with a previous cesarean delivery. Aust N Z J Obstet
Gynecol 38:96, 1998 [PMID: 9521403]
Scott JR: Mandatory trial of labor after cesarean delivery: An alternative viewpoint. Obstet
Gynecol 77:811, 1991 [PMID: 2030847]
Sheth SS: Results of treatment of rupture of the uterus by suturing. J Obstet Gynaecol Br
Commonw 75:55, 1968 [PMID: 4865061]
Shipp TD, Zelop CM, Repke JT, et al: Interdelivery interval and risk of symptomatic
uterine rupture. Obstet Gynecol 97:175, 2001 [PMID: 11165577]
Shipp TD, Zelop CM, Repke JT, et al: Intrapartum uterine rupture and dehiscence in
patients with prior lower uterine segment vertical and transverse incisions. Obstet Gynecol
63


94:735, 1999 [PMID: 10546720]
Smith GC, Pell JP, Cameron AD, et al: Risk of perinatal death associated with labor after
previous cesarean delivery in uncomplicated term pregnancies. JAMA 287:2684, 2002
[PMID: 12020304]
Socol ML, Peaceman AM: Vaginal birth after cesarean: An appraisal of fetal risk. Obstet
Gynecol 93:674, 1999 [PMID: 10912965]
Stovall TG, Shaver DC, Soloman SK, et al: Trial of labor in previous cesarean section
patients, excluding classical cesarean sections. Obstet Gynecol 70:713, 1987 [PMID:
3658277]
Tucker JM, Hauth JC, Hodgkins P, et al: Trial of labor after a one- or two-layer closure of
a low transverse uterine incision. Am J Obstet Gynecol 168:545, 1993 [PMID: 8438925]
Turner MJ: Delivery after one previous cesarean section. Am J Obstet Gynecol 176:741,
1997 [PMID: 9125596]
Vidaeff AC, Lucas MJ: Impact of single- or double-layer closure on uterine rupture
[letter]. Am J Obstet Gynecol 188:602, 2003 [PMID: 12592287]
Williams JW: A critical analysis of 21 years' experience with cesarean section. Bull Johns
Hopkins Hosp 32:173, 1921
Williams JW: Obstetrics: A Text-book for the Use of Students and Practitioners, 4th ed.
New York, Appleton, 1917
Wing DA, Lovett K, Paul RH: Disruption of prior uterine incision following misoprostol
for labor induction in women with previous cesarean delivery. Obstet Gynecol 91:828,
1998 [PMID: 9572178]
Wing DA, Paul RH: Vaginal birth after cesarean section: Selection and management. Clin
Obstet Gynecol 42:836, 1999 [PMID: 10572697]
Zelop CM, Shipp TD, Repke JT, et al: Effect of previous vaginal delivery on the risk of
uterine rupture during a subsequent trial of labor. Am J Obstet Gynecol 183:1184, 2000
[PMID: 11084564]
Zelop CM, Shipp TD, Repke JT, et al: Outcomes of trial of labor following previous
cesarean delivery among women with fetuses weighing > 4000 g. Am J Obstet Gynecol
185:903, 2001 [PMID: 11641675]
Zelop CM, Shipp TD, Repke JT, et al: Uterine rupture during induced or augmented labor
in gravid women with one prior cesarean delivery. Am J Obstet Gynecol 181:882, 1999
[PMID: 10521747]




Copyright 2007 The McGraw-Hill Companies. All rights reserved.
Privacy Notice. Any use is subject to the Terms of Use and Notice. Additional Credits and
Copyright Information.