Previous Caesarean Section
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Management of "Trial of Labour" (VBAC)
Women with previous lower segment caesarean sections should have antenatal care at their local clinics, but should be seen at least once by a doctor at a hospital antenatal clinic. Here a delivery plan can be discussed with the woman & the gestational age can be confirmed, if necessary, by an ultrasound scan. Women with a previous caesarean section are at increased risk of uterine rupture during labour. Labour & delivery must be conducted in hospital
Indications for elective repeat caesarean section
- A previous vertical uterine incision (classical & low vertical operations)
- Previous uterine rupture
- Two or more previous caesarean sections
- Previous pelvic floor or incontinence repair
- High risk of disproportion, e.g. EFW >3.5 kg, maternal short stature
- Where the woman requests an elective caesarean section
- Co-existing obstetric problem, e.g. multiple pregnancy, breech presentation
MANAGEMENT OF “TRIAL OF LABOUR” (VBAC)
- This is similar to normal labour with the following precautions:
- Run an intravenous drip with Ringer-Lactate solution at 120 mL/hour
- Give only clear fluids orally
- Insert a urinary catheter
- Monitor labour with continuous CTG
- Do 2 hourly cervical assessments
- Do not augment labour with oxytocin
- Strict adherence to correct partogram use
- Observe carefully for evidence of uterine rupture:
- Fetal tachycardia, decelerations or death
- Vaginal bleeding
- Haematuria
- Abdominal pain between contractions
- Sudden cessation of contractions
- Suggestive findings on abdominal palpation (tenderness, fetal extrusion)
- Presenting part not palpable or abnormally high on vaginal examination
Emergency caesarean section is recommended if:
- The membranes have ruptured and the woman is not in labour
- The latent phase of labour exceeds 8 hours
- Progress in the active phase of labour crosses to the right of the alert line (cervical dilatation rate <1 cm/hour)
- There is evidence of uterine rupture (above)
POSTPARTUM OBSERVATIONS
Observe the woman closely during the fourth stage of labour, as the uterus may rupture during delivery, with intra-abdominal, retroperitoneal, and/or vaginal bleeding. Routine palpation of the old uterine scar is not necessary. Signs of possible rupture, include:
- Rising heart rate
- A drop in BP
- Lower abdominal pain
- Severe lower abdominal tenderness
- Postpartum haemorrhage
- Haematuria
If uterine rupture is suspected, arrange laparotomy to repair the uterus. Inform the woman during the consent procedure that hysterectomy may be necessary.