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Azadeh Akbari Sene Assistant Professor in OBGYN/ IVF Fellowship Shahid Akbar-abadi IVF Center IUMS 1Azadeh Akbari Sene MD.

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Presentation on theme: "Azadeh Akbari Sene Assistant Professor in OBGYN/ IVF Fellowship Shahid Akbar-abadi IVF Center IUMS 1Azadeh Akbari Sene MD."— Presentation transcript:

1 Azadeh Akbari Sene Assistant Professor in OBGYN/ IVF Fellowship Shahid Akbar-abadi IVF Center IUMS 1Azadeh Akbari Sene MD

2  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 low- transverse 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 2Azadeh Akbari Sene MD

3  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% 3Azadeh Akbari Sene MD

4  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 (MFMU 2004, Chauban 2003, Mozurkewich 2000, Smith 2002) Is this risk acceptable? 4Azadeh Akbari Sene MD

5  Maternal mortality rate does not differ significantly (Landon 2004, Mozurkewich 2000)  Maternal morbidity rate (hysterectomy, uterine rupture, transfusion, infection) is significantly greater (MFMU 2004, Rossi 2008, McMohan 1996)  Increased incidence of overall maternal complications when failed VBAC compared to a successful VBAC (El- Sayed 2007, Rossi 2008) 5Azadeh Akbari Sene MD

6  Developing nomograms to help predict a successful trial of labor  Grobman nomogram 2007 (considering Age, BMI, Race, Vaginal delivery since last CS, Previous vaginal delivery, Recurrent primary indication)  Risk of rupture is not predictable with clinical characteristics (Srinivas 2007, Macens 2006, Grobman 2008) 6Azadeh Akbari Sene MD

7 ACOG recommendations for selecting appropriate VBAC candidates: 1. One previous prior low-transverse CS 2. Clinically adequate pelvis 3. No other uterine scars or previous rupture 4. Physician immediately available throughout active labor capable of monitoring labor and performing an emergency CS 5. Availability of anesthesia and personnel for emergency CS 7Azadeh Akbari Sene MD

8  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 incisionEstimated rupture rate (%) Classical4-9 T-shaped4-9 Low-vertical1-7 Low-transverse0.2-1.5 Prior lower segment rupture6 Prior upper uterus rupture32 8Azadeh Akbari Sene MD

9  Prior lower-segment vertical incision without fundal extension may be candidates for VBAC ?? (ACOG 2004)  It is helpful in the operative report to document the exact extent  Prior preterm CS (<34w)  higher uterine rupture rate ?? (Sciscione 2008)  Uterine malformation and prior CS: No significant risk (Erez 2007)  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 9Azadeh Akbari Sene MD

10 10Azadeh Akbari Sene MD

11 Women with  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 11Azadeh Akbari Sene MD

12  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 ↓ 12Azadeh Akbari Sene MD

13 Significant adverse neonatal morbidity has been reported with elective CS prior to 39 completed weeks 13Azadeh Akbari Sene MD

14 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 14Azadeh Akbari Sene MD

15  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 15Azadeh Akbari Sene MD

16  Wound/ uterine infection  Placenta previa  Transfusion  Hysterectomy  Placenta accreta  Bowel/bladder injury  ICU admission  Maternal mortality  Cesarean scar pregnancy 16Azadeh Akbari Sene MD

17 Thank you and have a nice day 17Azadeh Akbari Sene MD

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