CASE SCENARIO

27 years old, Madam M, G2P1, with 28

week of gestation, come to your clinic
for antenatal checkup. She had last
given birth 3 years ago via caesarean
section due to breech presentation.
She already discussed with her
husband to attempt vaginal birth for
this current pregnancy but not sure
what are the risks. How are you going
to counsel her?

VAGINAL BIRTH AFTER

LSCS

Background
In US for many decades, dictum of Cragin
ONCE A CESAREAN, ALWAYS A CESAREAN
was followed. It was put forth in 1916.
However in 1980, it was proposed that a trial
of labor after previous LSCS incision should
be attempt safely in selected patients.
Following this, concept of VBAC was
implemented.
Also known as trial of labor after cesarean
delivery (TOLAC)

Criteria For VBAC

No contraindication of vaginal birth.
One previous low transverse uterine
incision with no other uterine scar.
Clinically adequate pelvis
Physician is available throughout active
labor and capable to perform
emergency cesarean delivery.
Availability of anesthesia and nurse for
emergency cesarean delivery.

Benefits of VBAC

Reduce risk of thromboembolism

Shorter length of hospital stay
Less likely need for blood transfusion
Lower rate of
Post partum fever
Wound infection
Uterine infection
fewer neonatal respiratory problem

Contraindication to VBAC
Previous uterine rupture
Previous high vertical classical csection ( 200-900/10,000 risk of
uterine rupture)
3 or more previous caesarean
deliveries

Antenatal counselling
All women with previous LSCS should
be counseled about maternal and
perinatal risk and benefits of planned
VBAC and ERCS when deciding mode
of delivery.
Chances of successful planned VBAC
is 72-76%
Risk of uterine rupture after one
previous LCSC is 0.22-0.74%

Selection of Patients
1. Review Obstetric history and previous operative report
-. to determine type of uterine incision made on previous
caesarean section
-. to know information about last caesarean section
including any previous uterine scar.
2. Ascertain weather any contraindication for VBAC are
present
-. previous classical c-section
-. previous uterine surgery ( hysterotomy, deep
myomectomy, cornual resection and metroplasty)
-. previous uterine rupture or dehiscence
-. any maternal or fetal reason for elective c-section in
current pregnancy

VBAC with induction of labor

If induction of labor is required, the
following method can be considered:
1. Used Foley catheter to ripen the
cervix
2. Induction with prostaglandin E2 only
after review by consultant
obstetrician ( 2% risk of uterine
rupture)
3. Induction with oxytocin and artificial
rupture of membrane.

Intrapartum Management
1. Admitted at 38 weeks of gestation
2. Establish 16G cannula IV access, take blood for FBC
and blood group.
3. Monitor fetal wellbeing: continues CTG
4. Monitor maternal wellbeing:
-. maternal pulse hourly
-. BP and temperature 4 hourly.
5. First stage:
- use partogram for assessment of progress of labor
-. Epidural analgesia not contraindicated
-. Oxytocin augmentation not contraindicated (discuss
with obstetric consultant)

6. Second stage: ( most common time for scar

rupture)
- notify obstetric team when cervix considered fully
dilated
- acceptable to allow one hour for passive descent
at full dilatation when women have epidural.
- consult obstetric team if less expected progress
after 45 minutes of effective pushing
7. Third stage:
-active management recommended
-digital examination of scar is not advised
8. Early diagnose of uterine scar rupture, followed by
laparotomy and resuscitation to reduce morbidity
and mortality in mother and infant.

Features of uterine rupture

Abnormal CTG
Severe abdominal pain, persisting between
contractions
Chest pain or shoulder tip pain, sudden onset of
SOB.
Acute onset scar tenderness
Abnormal vaginal bleeding or hematuria
Cessation of previously efficient uterine activity
Maternal tachycardia, hypotension or shock
Loss of station of the presenting part on vaginal
examination.