3 Previous C-Scar

Case: 3 Previous C-sec scar

Question

a) Investigation

b) Management

c) Post op-acute management

d) U/S about placenta

Notes: According to ACOG guidelines on vaginal birth after Caeserean Section, trial of labor is not recommended in patients at high risk for uterine rupture. One of the contraindication including this case.

1) Two prior uterine scars and no vaginal deliveries

2) For women with 2 prior cesarean deliveries, only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor.

Notes: Therefore, the management of this patient should emphasize more on caesarean section and anticipating in possibility of uterine rupture.

Management also including advice for tubal ligation.

Investigation

Fetal investigation

- Ultrasound (AFI, Estimated fetal weight, exclude placenta previa, accrete or abruptio, biometry)

- CTG

Maternal (preparation for C-sec)

1) For patient in labour (fluid diet and T. Ranitidine 150 mg q.d.s)

2) Patient at high risk of anesthetic( sips of water+ IV fluid if indicated)

3) To cover the surgery

a) Consent form signed

b) Blood cross match (2U Pack cell)

c) IV ampicillin 1g stat for prophylactic

d) Bladder catheterization

e) Pre med (IV Ranitidine 50mg in 10 ml by slow injection, IV Maxalon 10 mg by slow injection, Sodium citrate 30 ml orally)

4) Anesthetist with at least one year experience

5) Ideally use regional block except contra indicated (major placenta previa, local skin sepsis, severe heart disease, coagulation disorder, severe fetal distress, cord prolapsed, eclampsia)

6) Present of obstetrician.

7) Reduce risk of thromboembolic phenomenon after surgery

a) Early ambulation

b) Anti embolic stocking/Flowtron

c) Anti coagulant for high risk cases.

[The practical Labour Suite Management]

Post op management

1) Recovery area (one to one observation until patient has airway control, cardio respiratory stability and can communicate)

2) In wards (1/2h observation RR, HR, BP, pain and sedation) for 2H, then hourly if stable

3) Intrathecal opiods- hourly observation for RR, Sedation and pain scores for 12h for diamorphines and 24h for morphines)

4) For epidural opiods and patient-controlled analgesia with opiods (hourly monitoring during CS, plus 2h after discontinuation)

5) Post natal care (analgesic, monitor wound healing, signs of infection)

6) consider CS complication (endometritis, thromboembolism, UTI, urinary tract trauma)

[NICE Guidelines on Caesarian Section]