KEHAMILAN DENGAN

BEKAS SECTIO CECAR

Disusun oleh : Heru Maranata Nababan

Pembimbing : DR. dr. Donel S, SpOG(K)
INTRODUCTION
INTRODUCTION
C-section is currently the most labor procedure performed on women
worldwide  and still increasing for various reasons.

The number of repeated C-sections are also increased due to decreased

vaginal delivery after the first C-section (Vaginal Birth After Section/VBAC).

Along with the increasing number of C-sections patients, the number of

surgical complications such as bleeding, intestinal attachment or bladder
attachment also increases.
INTRODUCTION
Cesarean section (SC)  surgical delivery procedure to give birth through
the incision of the abdominal and uterine wall.

C-section is considered in various conditions such as complicating factors in

labor (e.g. prolonged labor, uterine rupture, fetal distress, large fetus, and
bleeding after childbirth) and by the mother request.

History of cesarean section are not a mandatory for having C-section in the
next pregnancy and have another option by having a normal delivery
(Vaginal Birth After Caesarean (VBAC))

On contrary, VBAC has actually decreased since 1996 while primary and
repeat caesarean section rates increases
INTRODUCTION
The authors found a gap associated with an increase in the number of C-
section that continued to occur even though the number of complications was
also increased

VBAC delivery can reduce the incidence of complications due to C-section.

The authors suspected that there was a correlation between indications of

cesarean section in the first pregnancy and delivery in the second pregnancy,
affecting the rate of cesarean section at this time.
LITERATURE REVIEW
LITERATURE REVIEW
Pregnancy with prior history of C-section is a high-risk pregnancy  the
delivery must be done in a hospital with adequate facilities.

 should come to the hospital before entering labour and without any
complications

History of C-section are not a mandatory for having C-section in the next
pregnancy and they have another option by having a normal delivery
(Vaginal Birth After Caesarean (VBAC))

On contrary, VBAC has actually decreased since 1996 while primary and
repeated C-section rates increases
LITERATURE REVIEW

Figure 1. Percentage of SC in Government and Private Hospitals (Salfariani I, 2012).

LITERATURE REVIEW

Figure 2. Percentage of C-section worldwide (Blanchette H, 2011).

LITERATURE REVIEW
There are several indications that support a mother to undergo delivery
via C-section:

• Disproportion of Pelvic Head

• Case of fetal distress  Infection, Premature rupture of membranes
(PROM), Eclampsia (pregnancy poisoning).
• Placenta Previa
• Tranverse lie position
• Incoordinate Uterine Action
• Preeclampsia
• The mother dies, while the baby in the womb is still alive.
• Previous history of C-section
LITERATURE REVIEW
Sectio Caesarea can be classified into 3 types, namely:
1. Deep Transperitonealis C-Section
Low uterus segment incision.

Advantage:
Lesser risk of wound bleeding and peritonitis
Lesser danger on uterine rupture in the next pregnancy due its strong scar
tissue

2. Classic C-section
Mid-segment-10-12cm incision, with distal end above the vesicouterine
fold

Considered when  there is an obstacle on Deep Transperitonealis C-

Section procedure eg. uterus is attached to the abdominal wall due to
previous C-section

The disadvantage  greater risk of peritonitis and 4 times more danger

of uterine rupture in subsequent pregnancies.
LITERATURE REVIEW

3. Extraperitoneal C-section

Incisions in the wall and abdomen fascia + rectus musculus are bluntly
separated.

Bladder is retracted downward while the peritoneal fold is cut towards the
head to expose the lower segment of the uterus.

This type of surgery is done to reduce the danger of puerperal infection,

but with the progress of treatment for infection
 ANTENATAL CARE FOR MOTHER
WITH PRIOR HISTORY OF C-SECTION
The purpose of antenatal care is to provide more opportunities for health workers to
recognize early complications or risks that will occur in pregnant women

Antenatal care for mother with prior history of C-section is more focused on:

1. Determining gestational age, size of the fetus, and location of the fetus in the
uterus (especially in the third trimester of pregnancy)

2. Assess the condition of scarring and assess the any complications in the
previous from the prior C-section

3. Types of incision (low transversal, longitudinal/vertical/classic, or low vertical.

4. Every mother with prior C-section must give birth in a hospital with adequate
health facilities
 REFERRAL SYSTEM
The referral system in the obstetric field is an integrated health service system with
two-way interaction between midwives, GP, and specialists

Pregnancies with prior C-section have some potential obstetric emergencies such as
bleeding, hypertension, preeclampsia and eclampsia or other complications such as
location or presentation abnormalities, low APGAR score, placenta previa need
early referral planning.

Early planning  women are not yet in labour/have no complications of

childbirth No need spesific procedure/medicine

(Women could walk to the hospital easily and calmly)

MANAGEMENT FOR PREGNANCY WITH C-
SECTION HISTORY - VBAC
(VBAC) is a normal delivery process after having done cesarean section.

ACOG criteria for mothers with a history of cesarean section for vaginal
delivery as follows (ACOG, 2010):

• History of one low transverse cesarean section

• The strength of the pelvis is clinically strong
• Does not have scarring or any other history of uterine rupture
• There is a doctor who is able to monitor labor and perform emergency
C-section during active labor
• Availability of anesthesia and staff for emergency cesarean section
MANAGEMENT FOR PREGNANCY WITH C-
SECTION HISTORY - VBAC
To predict the successful management of VABC, several researchers made a
scoring system – Flamm and Geiger
MANAGEMENT FOR PREGNANCY WITH C-
SECTION HISTORY - VBAC
To predict the successful management of VABC, several researchers made a
scoring system – Weinstein Factor
MANAGEMENT FOR PREGNANCY WITH C-
SECTION HISTORY - VBAC
Absolute Contraindications for VBAC:

• History of Classic C-section

• History of C-section with T incision
• History of uterine rupture
• History of complicated C-section with extensive cervical laceration
• Other uterine incisions history in the uterine fundus, for example
myomectomy
• Cephalopelvic disproportion.
• The patient refuses vaginal delivery
• Narrow pelvis
• There are medical and obstetric complications which are contraindicated
vaginal delivery
MANAGEMENT FOR PREGNANCY WITH C-
SECTION HISTORY - VBAC
Maternal complications on VBAC:

1. Uterine rupture (acute abdominal pain, popping sensation, palpable parts

of the on Leopold's examination, deceleration and bradycardia in the baby's
heart rate, presenting scar is high on pervaginal examination, vaginal
bleeding)

2. Disorders of the thromboembolic system,

3. Endometritis
4. etc
 FACTORS AFFECTING VBAC
1. Previous surgery technique
Transverse uterine lower segment incisions  lower risk than other incision types.
Previous classic C-section, uterine T incision and complications  contraindications to VBAC.

2. Number of previous C-section

VBAC was not performed in patients with twice or more C-section consecutively

3. Wound healing in Previous C-section

Scar on previous classic C-section incision may not be able to recover and could open again
during the next pregnancy or labor
FACTORS AFFECTING VBAC
4. Indications of previous C-section

Indications of previous C-section VBAC Success (%)

Breech presentation
Fetal distress
Placental abruption
Placental previa
Failure of induction
Labor Dysfunction

5. Maternal age
Women over the age of 35 years have higher rates of C-section
 FACTORS AFFECTING VBAC
6. Gestational age during previous C-section
At <37 weeks gestational age and not yet in labour eg. placenta previa where the lower
uterine segment has not yet formed completely

7. History of vaginal delivery

Patients with cesarean section who have previous vaginal delivery have a higher rate of
VBAC

8. The condition of the cervix during labour

Thinning of the cervix and cervical dilation increases the success of VBAC.

Induction of labor with misoprostol will increase the risk of uterine rupture in the maternal
cesarean section (Macones GA, 2015).
 MANAGEMENT
If VBAC is not possible, labor is carried out with the C-section with technique options as
the following:

1. Classical C-section Technique

 MANAGEMENT
1. Classical C-section Technique

This technique is indicated for following reasons:

• Difficulty in separating the bladder for reach the lower uterine segment
• Large fetus in transverse lie
• Placenta previa with placental insertion on the front wall of the lower uterine segment
• Cesarean section followed by sterilization
• There are large blood vessels  tears and bleeding could occur in the lower uterine
segment
• The baby's head has entered the top of the pelvis.
• Grande multipara followed by hysterectomy
 MANAGEMENT
1. Classical C-section Technique

The advantages: The disadvantages:

• Easy to do • Healing of surgical wounds is longer

• Could deliver the fetus faster • Greater risk of uterine rupture for
• Does not cause bladder complications subsequent pregnancy
• The incision can be extended proximally • Greater risk of attachment to the
or distally (Luke B, 2017). abdominal wall. (Luke B, 2017).
MANAGEMENT
2. Deep Transperitonealis C-Section
 MANAGEMENT
2. Deep Transperitonealis C-Section

Maternal Indications Fetal indications

• In primigravida with location abnormalities
• Elderly primigravida with malposition and CPD • Fetal distress
• A history of poor pregnancy and childbirth • Malpresentation and malposition
• Narrow hip • Prolapse of the umbilical cord with a
• Placenta previa especially in primigravida small cervix dilation
• Placental abruption • Failure of vacuum or forceps extraction
• Complications of pregnancy, eg preeclampsia to
eclampsia
• Vaginaplasty
• Impaired labor due to cysts, uterine myoma,
cervical carcinoma, uterine rupture.
• Pregnancy accompanied by diseases, such as
heart disease, and diabetes mellitus
MANAGEMENT
2. Deep Transperitonealis C-Section

The advantages of this technique include:

• Calmer lower segment of the uterus
• Better wound healing
• Does not cause a lot of adhesion

The disadvantages of this technique include:

• Difficult fetal delivery
• An extended incision could cause bleeding
MANAGEMENT
3. Hysterectomy C-section
COUNSELLING
 COUNSELLING
Pregnancy and childbirth with a prior history of C-section will run the risk of increased
morbidity and mortality related to uterine scarring.

Every pregnant woman with prior history of C-section should have an antenatal examination
 to get information about the estimated date of delivery

The examinations should be done in a hospital that has adequate health facilities, and when
the time is right, the baby need to be delivered in hospital minimize the possibility of
fatal complications
THANKYOU