Transcript Azadeh Akbari Sene Assistant Professor in OBGYN/ IVF Fellowship Shahid Akbar-abadi IVF Center IUMS Azadeh Akbari Sene MD.

Azadeh Akbari Sene
Assistant Professor in OBGYN/ IVF Fellowship
Shahid Akbar-abadi IVF Center
IUMS
Azadeh Akbari Sene MD
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Cragin 1916: once a CS, always a CS
Kerr 1920s: Low-transverse incision with 0.5% chance of
uterine rupture
Hellman 1971: 30-40% VBAC
Merrill 1978: 83% VBAC in Texas university
ACOG 1988: most women with one previous lowtransverse CS should be counseled to attempt labor
VBAC 1996: One third of prior CS
ACOG goal for 2010: VBAC i0f 37% in women at 37
weeks or more with singleton cephalic pregnancy with a
prior Kerr incision
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After 1989: growing number of uterine rupture and
adverse prenatal outcome with VBAC
Hamilton 2009: primary CS rate>30% , VBAC rate
dropped to 8.5%
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Higher uterine rupture rate but only 7 in 1000
 Higher rates of stillbirth and HIE
 Absolute rate of uterine rupture resulting in fetal death
or injure = 1 per 1000
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(MFMU 2004, Chauban 2003, Mozurkewich 2000, Smith 2002)
Is this risk acceptable?
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Maternal mortality rate does not differ significantly (Landon
2004, Mozurkewich 2000)
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Maternal morbidity rate (hysterectomy, uterine rupture,
transfusion, infection) is significantly greater (MFMU 2004, Rossi
2008, McMohan 1996)
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Increased incidence of overall maternal complications
when failed VBAC compared to a successful VBAC (ElSayed 2007, Rossi 2008)
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Developing nomograms to help predict a successful
trial of labor
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Grobman nomogram 2007 (considering Age, BMI, Race, Vaginal
delivery since last CS, Previous vaginal delivery, Recurrent primary
indication)
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Risk of rupture is not predictable with clinical
characteristics (Srinivas 2007, Macens 2006, Grobman 2008)
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ACOG recommendations for selecting appropriate VBAC
candidates:
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One previous prior low-transverse CS
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Clinically adequate pelvis
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No other uterine scars or previous rupture
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Physician immediately available throughout active labor
capable of monitoring labor and performing an emergency CS
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Availability of anesthesia and personnel for emergency CS
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Highest risk of rupture with prior vertical incision
extending into fundus
The risk of classical scar rupture before the onset of
labor or several weeks before term
Prior incision
Estimated rupture rate (%)
Classical
4-9
T-shaped
4-9
Low-vertical
1-7
Low-transverse
Prior lower segment rupture
Prior upper uterus rupture
0.2-1.5
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Prior lower-segment vertical incision without fundal extension
may be candidates for VBAC ?? (ACOG 2004)
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It is helpful in the operative report to document the exact extent
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Prior preterm CS (<34w)  higher uterine rupture rate ?? (Sciscione
2008)
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Uterine malformation and prior CS: No significant risk (Erez 2007)
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One versus two layer closure of incision: insufficient evidence ??
The type or prior incision is the most important factor for
considering a trial of labor
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Women with
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Prior uterine rupture
Classical or T-shaped incisions
Should undergo repeat CS when fetal pulmonary
maturation is assured
Preferably prior to the onset of labor
Counseling for warning signs
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Inter-delivery interval: at least 6 months for complete
uterine scar healing (18 months?)
Number of prior CS?
Prior vaginal delivery: The most favorable prognostic factor
Considering VBAC with two previous CS in women with
prior vaginal delivery
Indication for prior CS: lower success rate with dystocia
Fetal size↑  risk of rupture↑
Preterm fetus  risk or rupture ↓
Multifetal gestation : No increased risk
Maternal obesity: success rate ↓
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Significant adverse neonatal morbidity has been
reported with elective CS prior to 39 completed weeks
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Any attempt to stimulate cervical ripening or to induce or
augment labor  uteirne rupture risk ↑
 Oxytocin: infusion dose ↑  uterine rupture risk ↑
 Prostaglandins: uterine rupture risk ↑
 Sequential prostaglandins and oxytocin  more
increased risk
 EASI ? Laminaria? Stripping?
 Epidural analgesia: may safely be used
 Uterine scar exploration: only if significant bleeding is
encountered
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Cochrane matanalysis 2013:
There is insufficient data available from RCTs on which
to base clinical decisions regarding the optimal method
of induction of labor in women with a prior cesarean
birth
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Wound/ uterine infection
Placenta previa
Transfusion
Hysterectomy
Placenta accreta
Bowel/bladder injury
ICU admission
Maternal mortality
Cesarean scar pregnancy
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Thank you and have a nice day
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