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(TRIAL OF SCAR)
Definition
Planned VBAC (vaginal birth after caesarean) refers to any woman who has experienced a prior caesarean birth who plans to deliver vaginally rather than by ERCS (elective repeat caesarean section).
Recommendation
Vaginal birth after caesarean section (VBAC) should be considered as an option for all women who present for antenatal care with a history of previous caesarean birth. Where contraindications exist, a repeat caesarean section should be advised, but in the majority of cases successful vaginal birth can be achieved safely for both mother and baby. The success rate is up to 72-76% for birth after a single previous caesarean section
All women who have experienced a prior caesarean birth should be counselled about the maternal and perinatal risks and benefits of planned VBAC and ERCS when deciding the mode of birth. Where possible, there should be review of the operative notes of the previous caesarean to identify the indication, type of uterine incision and any perioperative complications.
Enter the labor spontaneously Favourable cervix Previous caesarean section for non-recurring indication
Contraindication of TOS
Previous classical or T-inverted uterine scar
increased risk of uterine rupture
Previous hysterotomy or myomectomy entering the uterine cavity Previous uterine rupture Previous perforated uterus Previous cornual pregnancy two or more previous caesarean deliveries
the rates of hysterectomy and transfusion were increased
Risk of VBAC
All women who have experienced a prior caesarean birth should be counselled about the maternal and perinatal risks and benefits of planned VBAC and ERCS when deciding the mode of birth. Uterine rupture
Planned VBAC carries a risk of uterine rupture of 2274/10,000. There is virtually no risk of uterine rupture in women undergoing ERCS.
The risk of respiratory problems in the newborn is increased in ERCS (6% vs. 3%), compared with women who have a successful VBAC
The following risks significantly increase with increasing number of repeated caesarean deliveries: injury to bladder, bowel or ureter need for postoperative ventilation intensive care unit admission blood transfusion requiring four or more units placenta accreta hysterectomy
knowledge of the womans intended number of future pregnancies may be an important factor to consider during the decision-making process for either planned VBAC or ERCS
Trial of scar can only be contemplated when appropriate personnel and facilities are available:
Obstetrician Anaesthetist Paediatrician Operation theatre Blood transfusion
When fetal head is 2/5th and lower, induction of labor may be considered with extra caution.
Uterine rupture
complete separation of the myometrium with or without extrusion of the fetal parts into the maternal peritoneal cavity and requires emergency Caesarean section or postpartum laparotomy. It is an uncommon complication of VBAC but is associated with significant maternal and perinatal morbidity and mortality
Planned VBAC carries a risk of uterine rupture of 2274/10,000 Induction and augmentation carry 2-3 times risk of uterine rupture compared to spontaneous labor in VBAC
There is no single pathognomic clinical feature that is indicative of uterine rupture but the presence of any of the following peripartum should raise the concern of the possibility of this event:
severe abdominal pain, especially if persisting between contractions chest pain or shoulder tip pain, sudden onset of shortness of breath acute onset scar tenderness abnormal vaginal bleeding haematuria cessation of previously efficient uterine activity maternal tachycardia, hypotension or shock Palpable scar defect or fetal part loss of station of the presenting part. abnormal CTG
Fetal tachycardia or absent fetal heart activity Fetal distress
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