> Information for the birth the pregnant woman with previous Caesarean section

Dear Madam,

In the past she has given birth by caesarean section. This condition, while resulting in a slight increase in the risk of rupture of the uterus, does not constitute an absolute contraindication to an attempt of labor aimed at vaginal delivery is defined in the literature “labor test“.

we therefore Believe it proper to provide a series of information about this condition, derived in large part from the literature and from the Guidelines of the main Companyà of Obstetrics, as well asé drawn from our experience. On the basis of these information, ask the orientation on the modeà delivery.

of course, it is possible to integrate any further clarification from staff Physician/Obstetrician who is accompanying in the course of her pregnancy.

Disadvantages of a caesarean section, repeated

Perform a delivery by caesarean section after a previous caesarean, not is without risks and disadvantages, which can be così summaries:

    the

  • surgery più long and sometimes più difficult because of the scar tissue a cesarean section repeated usually lasts longerù, può be più difficult and with higher risk of damage to the bowel or bladder.
    the

  • Increased ability of the vascular accidents of the type of thromboembolism (0,4 vs 1 out of a thousand between the vaginal delivery and the TC is repeated).
    the

  • physical Recovery più slow (compared to the good outcome of a vaginal delivery that it is not possible to predict with absolute certainty): the hospital stay is generally più long and può be required to help to return home.
    the

  • drag and drop and more caesarean sections in subsequent pregnancies, becauseé with the increase in the number of caesarean sections also increase the risk of rupture of the uterus during labor pains
    the

  • Ability of a plant pathological placenta (placenta previa and accreta) in subsequent pregnancies: for each caesarean section will always form more scar tissue, and this increases the possibilityà that the placenta develops too low (placenta previa) or within the scar of the womb, making separation at the time of caesarean section, very difficult (placenta accreta). Talecomplicazione può determine blood loss significant, sometimes it will be necessary to remove the uterus (incidence of placenta previa and accreta is 0.5 to 10,000 after 1 caesarean section and doubles after 2 c-sections).

 Benefits of giving birth vaginally

    the

  • To against the advantages of a delivery was vaginal without complications, are the following:

  • birth Event più physiological and natural, and more satisfying for the mother
    the

  • Higher probability; parts that are not complicated in future pregnancies
    the

  • Lower abdominal pain after childbirth
    the

  • physical Recovery, more rapid and shorter duration of hospital stay
    the

  • Proximity continues the mother-child and best-fitting post-christmas

Disadvantages of giving birth vaginally

The main fear that characterizes labor pains in a patient that has been previously submitted to caesarean section and the possible rupture of the uterus at the point of transverse incision of the lower uterine segment of the previous TC. event that in the trials available in the literature occurs with a frequency that ranges from 3 to 8 cases out of a thousand.

it is correct to say that this event può taking in vaginal deliveries without previous CT, and in this case, the frequency described, and’ of 1-2 cases out of a thousand.

The risk of fetal death is extremely low, however, is estimated to be higher in women who face a labor test (about 10 to 10,000 parts) than those undergoing Caesarean section, elective (about 1 to 10,000 parts). Probably thereò you è due to the fact that the continuation of pregnancy beyond 40° week in cases with labor test exposes the fetus to accidents intrauterine not always predictable.

The consequences of the rupture of the uterus: in 14-33% of cases, it is necessary to remove the uterus with the consequent sterilità in the future; in 6% of cases, rupture of the uterus is associated fetal death; there is a greater risk of surgical complications when the caesarean section is performed in emergency because of this complication.

The advantages of a Caesarean section, repeated

    the

  • knowledge of The date of the delivery
    the

  • reduced Risk of rupture of the uterus
    the

  • Lower risk of perinatal asphyxia (brain damage caused by poor oxygenation during the delivery), present in 1 case in 2000 in children born via the vaginal tract
    the

  • Lower risk of brachial plexus injury at the time of childbirth (the lesion of the fetal attorney paralysis of the arm). The risk of this injury is 1 in 600 babies born vaginally and 1 in 3000 babies born with caesarean section.

Contraindications to childbirth by vaginal

In any case, the choice to carry out a caesarean section is considered to be the più safe. In particular, in the following cases:

Patient has già was submitted to a 2 (or more) caesarean sections. With 2 c-sections previous the risk of rupture of the uterus is tripled. In our maternityà in such cases, it is possible to face the ordeal of trial .

    the

  • Previous rupture of the uterus in the course of the previous labor
    the

  • Previous incision transverse on uterus
    the

  • Any complication or pathology of pregnancy that represents a new indication for cesarean section

 Conditions that increase the probability; of the success of the travail of test:

    the

  • Età less than 40 years
    the

  • Previous birth via the vagina (even more if the previous delivery via the vagina is occurred after a previous caesarean section)
    the

  • in the Presence of conditions favourable to the dilatation of the cervix
    the

  • Non-recurrence of the clinical indication of the previous cesarean section

Conditions that reduce the probability; of the success of the travail of test:

    the

  • gestational Age greater than 40 weeks. After this term will be made periodic checks at the outpatient clinic for surveillance of prenatal. If these are normal you canà reasonably wait for 7-10 days.
    the

  • Weight neonatal estimated more than 4000 gr.In such cases, valueà case by case the opportunityà or not to deal with this type of delivery (as a function of the visit, midwife, weight and height of the maternal, of the metabolic conditions of the mother, or of the ultrasound evaluated together, etc).
    the

  • induced labor or piloted with prostaglandins and/or oxytocin. In our maternityà you è decided not to use these medications in the “labors of the test.

Interval of time since the previous caesarean section

A figure that recurs in the literature indicates a higher frequency of rupture of the uterus when the travail of the test is realized in a time close to the previous cesarean section. If the interval from the previous caesarean section is less than 18 months, not sarà can make a labor trial in this maternityà.

Induction of labor

In certain situations (pregnancy, protracted, reduced amniotic fluid volume, increase in pressure etc) it is possible to need to speed up the delivery, and often, in women not previously subjected to caesarean section, use the induction of labor.

Sinceé in his case this procedure would result in a slight further increase in the risk of rupture (estimated at a probability; about 3 times greater than the data described above) in our maternityà you è decided not to do this.

Thereò determines that in the presence of a prolongation of pregnancy (after 7-10 days of waiting since the end of the 40° week), or earlier if these terms suggest that the accomplishment of the delivery, not being able to resort to induction of labor, you effettuerà again, a caesarean section.

Use of oxytocin in labor

oxytocin is often administered during labor to augment or regulate the activity; contractile uterine. Also this practice results in a slight increase of the risk of rupture of the uterus. In addition, the use of this medication in women già cesarizzate not è allowed by the technical ministry. Therefore, in our maternityà, you è decided not to use it. Thereò means that, in the case of prolonged labour you may have to repeat the caesarean section

Delivery-Analgesia and fetal monitoring

In the past it was feared that the analgesia epidural could mask the presence of pain (persistent between one contraction and another) as a sign of a greater risk of rupture. In realityà subsequent studies have not confirmed this association.

While there is no literature specific contraindications to the implementation of an analgesia in labor in childbirth after a previous caesarean section, the use of this analgesia può slow down the labor, and this condition often requires the administration of oxytocin.

Not being able to use this therapy, you è decided in our maternityà not to use the epidural in labor trial. The sign più municipality of rupture of the uterus is represented by the anomalies of the fetal heart rate.

For this reason, in the course of active labor (dilated more than 3-4 cm) will beà maintained a monitoring cardiotocographic continuous, allowing only short periods of suspension (e.g. to go to the bathroom). This practice obbligherà the position in bed during the entire duration of labor.

Pratiche ostetriche

To cope with greater security, any hemorrhagic complications during and after childbirth sarà should be (a) before admission to perform a Type & screen (typing and screening, antibody) in order to accelerate the supply of blood to part of the centre emotrasfusionale if it is necessary (for such an examination is necessary to go in the morning within the hours of 9:30 at the department of obstetrics – floor, at the end of the 37° week of pregnancy); at the beginning of labor to apply a agocannula to be able to give the più quickly as fluids and medications if necessary.

Note aggiuntive

This information has been provided, discussed and released by dr.

In data ____/___/201..

I, the undersigned, già subjected previously to a caesarean section, I have been informed about the possible complications that may arise in carrying out the childbirth for both vaginal as well asé about the risks and benefits that arise from repeating a caesarean section. Therefore:

    the

  • ask you to try a travail to give birth vaginally, and I agree to the decisions midwives and surgical procedures may be necessary (caesarean section, emergency – blood transfusion – hysterectomy
    the

  • are not willing to try a birth via the vagina and ask you to repeat a caesarean section

please note: we reserve the right to assess collectively its request to assess the entity; risk and commisurarlo to our potentialà clinical care and instrumental

Roma, _____/____/201..

The expectant mother, The gynecologist

__________________________ ________________________

Bibliography consulted

Guidelines for Vaginal Birth After Previous Caesarean Birth, SOGC Clinical Guidelines, N. 155 (Replaces guideline No 147), February 2005

National Institutes of Health Consensus Development Conference Statement. Vaginal Birth After Cesarean: New Insights March 8–10, 2010. Ob & Gyn vol. 115, No. 6, June 2010

Birth after previous caesarean birth, RCOG Green-top Guideline No. 45

Vaginal Birth After Previous Cesarean Delivery. Practice Bulletin Number 115, August 2010

Uterine rupture after previous caesarean section. Al-Zirqi I, Stray-Pedersen B, Forse’n L, Vangen S. BJOG 2010;117:809–820.

We would like to thank the UOC of obstetrics and gynaecology, university Hospital Christ the King of Rome for the kind permission to publish

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