Transcript PREVIOUS C.S. - Netmedico | A medico hangout

PREVIOUS C.S.
Pregnancy with history of previous C.S. is
quite prevalent in present day obstetrics
According to the statistics available the
total cesarean rate has increased every
year and in the year 2002 it was 26.1%
Since the rate of primary C.S. has
increased the most remarkable change in
obstetric practice over the last decade is
the management of the women with prior
Cesarean delivery.
Routine obstetric history
Past surgical history
To ascertain functional and structural integrity of the scar
Selection of patients for VBAC
Criterion for VBAC
No more than one prior low transverse cesarean delivery
Clinically adequate pelvis
No other uterine scars or previous rupture
Physician immediately available throughout active labour
who is capable of monitoring labour and performing
cesarean delivery
Availability of anesthesia and personnel for emergency C.S.
To ascertain functional and structural integrity of
the scar
1.Indication for C.S.
RECURRENT
CPD
Previous classical C.S
Previous two LSCS
NON-RECURRENT
Malpresentations Failed
Induction Failure to
progress APH
BOH
Hypersensitive disorders
or associated complications
2.Type of C.S.
LSCS
Classical
Apposition
Thin cut margins facilitate
perfect opposition without
leaving any pocket
Difficult to oppose thick muscle layer.
Packets are formed which contain
blood and are subsequently replaced
by fibrous tissue
State of
uterus
during
healing
The part of uterus remains
while healing process is going
on
The part of uterus contracts and
retracts so that the sutures become
loose leading to imperfect healing
Stretching
effect
The scar is made to stretch
during future pregnancy and
normal labour more along the
line of scar
The stretch is at right angles to the
scar
Placental
implantation
Chance of weakening the scar
by placental attachment is
unlikely
Placenta is more likely to implant on
scar and weakens it by trophoblastic
penetration or herniation of amniotic
sac through the gutter
Net effect
Scar is sound. Rupture is less
and if occurs it is only during
labour 0.2 to 1.5%
Following rupture maternal
death rare
Perinatal death 1 in 8
Scar is weak rupture may occur both
during pregnancy and labour 4% to
9%
Following rupture Maternal death 5%
Perinatal death 6 in 8
Total number of C.S. done before
Time interval between successive
pregnancy and LSCS
history of vaginal births after delivery
If operative notes are available
Complications during surgery
Type of incision, extension of incision
Inverted T shaped incision
Suturing method
Single layered, two layered, three layered
Suturing material used -catgut / vicryl
Post operative stay
Wound healing: Day of suture removal,
Resuturing, infection of wound etc.
History of associated present pregnancy
complications
Patient in labour
Pain in abdomen specially in supra pubic region
Vaginal bleeding
Bladder Tenesmus Haematuria
In scar dehisence -Various degrees of shock
Intelligent patient may say giving way sensation
with decrease in pain and uterine contractions
Absence of fetal movements
On Examination:
Patient not in labour
Look for anemia, PIH
Type of incision - Pfennsteil incision / Vertical
incision
Type of healing - Primary intension /Secondary
Intension
Associated keloid formation, Incisional hernia
Abdominal examination
Presence of Malpresentation, CPD, placenta
previa
Estimated fetal weight
Patient in labour
Signs of impending scar rupture
Unexplained tachycardia
Fall in blood pressure
Fetal distress – abnormal FHS
Bradycardia
Tenderness over uterine scar
Failure to progress in the course of labour
without any apparent cause
Ballooning of lower uterine segment
In case of scar Dehisence
Patient may present with various degrees of shock
Signs of shock
Early phase
Tachycardia
Excessive sweating
Normal BP
Intermediate phase
Consciousness is altered
Appears pale dehydrated with sweating
Periphery cold
Tachycardia
Hypotension
Urine output will be normal
Late
Patient may be in confusional state
Pallor increases
Tachycardia, thready pulse with low pulse volume
Cold clammy extremities
Oliguria
Tachyopnoea
Bleeding
Abdominal examination
Fetal parts felt superficially
FHS absent
Uterus may be felt separately