1. PREVIOUS C.S.

2. 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.

3. 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.

4. To ascertain functional and structural integrity of the scar 1.Indication for C.S. RECURRENTCPD Previous classical C.S Previous two LSCS NON-RECURRENT Malpresentations Failed Induction Failure to progress APH NON-RECURRENT Malpresentations Failed Induction Failure to progress APH BOH BOH Hypersensitive disorders or associated complications Hypersensitive disorders or associated complications

5. 2.Type of C.S. LSCSClassical 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

6. 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 Complications during surgery Type of incision, extension of incision Type of incision, extension of incision Inverted T shaped incision Inverted T shaped incision Suturing method Suturing method Single layered, two layered, three layered Single layered, two layered, three layered Suturing material used -catgut / vicryl Suturing material used -catgut / vicryl Post operative stay Wound healing: Day of suture removal, Resuturing, infection of wound etc. Resuturing, infection of wound etc.

7. 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

8. 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

9. Patient in labour Signs of impending scar rupture Unexplained tachycardia Unexplained tachycardia Fall in blood pressure Fall in blood pressure Fetal distress – abnormal FHS Bradycardia Fetal distress – abnormal FHS Bradycardia Tenderness over uterine scar Tenderness over uterine scar Failure to progress in the course of labour without any apparent cause Failure to progress in the course of labour without any apparent cause Ballooning of lower uterine segment Ballooning of lower uterine segment

10. In case of scar Dehisence Patient may present with various degrees of shock Signs of shock Early phase Tachycardia Tachycardia Excessive sweating Excessive sweating Normal BP Normal BP Intermediate phase Intermediate phase Consciousness is altered Consciousness is altered Appears pale dehydrated with sweating Appears pale dehydrated with sweating Periphery cold Periphery cold Tachycardia Tachycardia Hypotension Hypotension Urine output will be normal Urine output will be normal Late Late Patient may be in confusional state Patient may be in confusional state Pallor increases Pallor increases Tachycardia, thready pulse with low pulse volume Tachycardia, thready pulse with low pulse volume Cold clammy extremities Cold clammy extremities Oliguria Oliguria Tachyopnoea Tachyopnoea Bleeding Bleeding

11. Abdominal examination Fetal parts felt superficially FHS absent Uterus may be felt separately