Vaginal Delivery with Vacuum Extraction

after Cesarean Section

Febianza Mawaddah Putri
41131096000036

Supervisor: dr. Arvid Tardan, SpOG

Tuesday, October 10th 2017

DEPARTEMENT OF OBSTETRICS AND GYNECOLOGY | FATMAWATI GENERAL HOSPITAL |

FACULTY OF MEDICINE, ISLAMIC UNIVERSITY OF JAKARTA | PERIOD AUGUST 7th – OCTOBER 15th 2017
 OUTLINE
• Introduction
• Theory
• Case Illustration
• Case Analysis
• Discussion
INTRODUCTION
 Introduction
20th century most Research done after Vaginal Birth
people believe 1960 gave evidence
“once a cesarean, “History of Caesarean
After Cesarean
always cesarean.”  Vaginal delivery” (VBAC)

>> Advantage:
• Avoidance of major surgery
• Lower risk of hemorrhage and
infection
• Shorter recovery periods
The Rate of C-Section and VBAC
THEORY
 Indications for C-Section

Primary Repeat
3% 0.4%
17%
Dystocia No VBAC attempt
20%
Nonreassuring fetal Failed VBAC
37% heart rate
Abnormal Unsuccessful trial of
presentation forceps or vacuum
82%
Unsuccessful trial of
forceps or vacuum

25%
 Complications of C-Section
Intraoperative Complications Postoperative Complications
 Infections  Thromboembolic
 Organ injury (bladder, complications (embolism,
intestines, ureter, etc) thrombosis)
 Risks association with  Adhesions
anesthesia  Persistent pain
 Need for blood transfusions
 Hysterectomy as a treatment
for severe bleeding (e.g. from
placenta previa)

Mylonas I, Frlese K. Indications for and Risks of Elective Cesarean Section. Dtsch Arztebl Int 2015; 112: 489-95.
 VBAC
• Purpose : for reducing the cesarean section (CS) rate.
• Planned VBAC is appropriate for and may be offered to the :
- majority of women with a singleton pregnancy of cephalic
presentation at 37 weeks or beyond
- who have had a single previous lower segment caesarean
delivery
- with or without a history of previous vaginal birth.

RCOG Green-top Guideline no.45, 2015

 Risk Factors
• Previous uterine rupture
• Type of previous uterine incision : previous inverted T or J
incisions, low vertical uterine incisions, previous classical
cesarean delivery due to the high risk of uterine rupture
• Previous uterine surgery : hysterectomy or myomectomy
entering the uterine cavity
• Presence of a contraindication to labor, such as placenta
previa or malpresentation

RCOG Green-top Guideline no.45, 2015

 TOLAC
Trial of Labor After Cesarean Delivery
 TOLAC  provides women who desire a vaginal delivery with the
possibility of achieving that goal--a VBAC.
 The risks: maternal hemorrhage, infection, operative injury,
thromboembolism, hysterectomy, and death.

American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115. Vaginal birth after previous cesarean delivery. Obstet
Gynecol. 2010;116(2):452.
 Table 7. Factors Associated with Successful TOLAC
Increased probability of success
 Previous vaginal birth
 Spontaneous labor
Decreased probability of success
 Gestational age greater than 40
weeks
 Increased maternal age
 Increased neonatal birth weight
 Maternal obesity
 Nonwhite ethnicity
 Preeclampsia
 Recurrent indication for cesarean
delivery
 Short interpregnancy interval

American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115. Vaginal birth after previous cesarean delivery. Obstet
Gynecol. 2010;116(2):452.
 ERCS
Elective Repeated Cesarean Section
For woman that contraindicated for attempting VBAC  ERCS
Benefits Risks
 Avoid late stillbirth (after 39 weeks)  Surgical morbidity and complications
 Reduced perinatal mortality and both with index pregnancy and further
morbidity (especially HIE) related to pregnancies
labor, delivery, and scar rupture  Increased risk of neonatal respiratory
 Reduced maternal risks associated with morbidity – low incidence ≥39 weeks
emergency CS gestation
 Avoidance of trauma to the maternal  Associated with lower rates of initiating
pelvis floor breast feeding
 Convenience of planned date for birth

RCOG. Birth After Previous Caesarean Section. 2010.

 VBAC Planned VBAC
Maternal Outcome : Maternal Outcome :
ERCS

or  Shorter hospital stay and recovery

 0.5% risk of uterine scar rupture.  Able to plan a known delivery date in select
ERCS  Increases likelihood of future vaginal birth
 Risk of maternal death with planned VBAC of
patients.
 Virtually avoids the risk of uterine rupture
??? 4/100 000  Longer recovery
 Reduces the risk of pelvic organ prolapse
Infant Outcomes : and urinary incontinence
 Risk of transient respiratory morbidity of 2-  Option for sterilisation if fertility is no
3% longer desired
 8 per 10 000 (0.08%) risk of hypoxic  Future pregnancies – likely to require cesarean
Ischaemic encephalopathy (HIE) delivery, increased risk of placenta
 4 per 10 000 (0.04%) risk of delivery-related praevia/accreta and adhesions with successive
perinatal death. caesarean deliveries/abdominal surgery
 Risk of maternal death with ERCS of 13/100
000

Infant Outcomes :
 Risk of transient respiratory morbidity of 4-5%
 <1 per 10000 (<0,01%) risk of delivery related
perinatal death or HIE
RCOG. Birth After Previous Caesarean Section. 2010.
 Operative Vaginal Delivery
Vaginal delivery wich is assisted by forcep or vacuum extractor

Indication
Maternal
• Slow progress in the second stage due to:
• Poor contraction and/or maternal fatigue
• Epidurals may diminish contractions and blunt maternal pushing
efforts
• A thight unyielding perineum may require an episiotomy rather than
the use of forceps or vacuum extractor
Fetal
• Non-reassuring fetal heart surveillance, according to recognized
definition
British Columbia Reproductive Care Program. Assisted Vaginal Birth: The Use of Forceps or Vacuum Extractor. 2001.
CASE ILLUSTRATION
 Case Illustration
• Name : Mrs. JL
• Medical record : 01538820
• Date of birth : Ngawi, July 3rd 1988
• Age : 29 year old
• Address : Jatipuro, Ngawi
• Religion : Moslem
• Ethnicity : Java
• Occupation : Housewife
• Education : University
• Admission time : September 27th 2017
 Chief Complain
Patient comes to hospital because of contraction and history
of C-section 1x (referred from Mutia midwife).

The anamnesis was done on September 27th 2017 at 2.50 AM

 History of present illness
• Admitted 9 months of pregnancy.
• LMP December 22th 2016, EDD September 29th 2017 ~ 39 wga
• ANC regularly in midwifery every month.
• USG 1x at September 6th 2017 ~ 36 wga
• Contraction since 20 hours before admission. Has an active fetal movement.
• No complaints about mucous and blood spots from genitalia, water broke,
vaginal discharge, urinate abnormality, and fecal abnormality.
• No complaints about headache, upper abdominal pain, blurred vision in this
pregnancy.
• Patient has 1 prior caesarean section delivery in 5 years ago (2012) due to
premature rupture of membrane.
 Addition….
History of past illness
• DM (-), hepatitis (-), hypertension (-), stroke (-), cardiac disease (-), TBC
(-), cancer (-), allergy (-)
• Surgical history: C-section in 2012 due to premature rupture of
membrane.
Family history
• DM (-), hypertension (-), renal disease (-), cardiac disease (-), allergy (-)
History of menstrual period
• Menarche: 12 year old, 7 days, 2 pads/day, dysmenorrhea (-)
History of marriage
• Married once, 1st marriage: 3 years, still married.
 Addition….
Obstetrical history
• G2P1A0:
1) 2012, caesarean delivery at RSUD Ngawi by doctor, male 3450 gram,
alive
2) Current pregnancy
Contraception history
• Patient never used contraception.
Social and lifestyle history
• Smoking(-), alcohol consumption(-), drugs(-), herbals(-), excess
activity(-). Patient eats 3x/day regularly.
 Physical Examination & Supporting Examination
• General Condition : Good Obstetrical examination
FUH : 33 cm
• Level Of Conciousness : CM EFW: 3410 gram
• Anthropometry : Weight 65 kg, His : 2-3x/10’/35”
height 160 cm, BMI 25.4 kg/m2 Contractions : Active
• Vital sign : BP 110/70mmHg, HR FHR : 148 bpm
Inspection : Bloody show (+)
92x/min, RR 20x/min, temp
Inspeculo : Not examined
36,2°C VT : Ø 9 cm cervix dilation, head in H III,
amniotic membrane (-)
General status: wnl
Laboratory findings
CBC 11.2/ 34/ 18700/337000// 85.0/ 28.1/ 33.1/ 12.8
The 1st physical examination was done on USG:No data
September 27th 2017 at 2.50 AM at CTG : Category I
Emergency Room of Fatmawati Hospital
 Diagnosis & Treatment
Diagnosis
Active phase of Stage I on G2P1A0 39 wga. Singleton live head fetal
presentation, prior caesarean section 1x, interval of delivery time 5 years
Treatment
- Observation of general condition, vital sign, FHR, contraction
- CBC, complete urinalysis, blood glucose, PT/APTT
- CTG
- VBAC
Process
Ǿ 9 cm, CTG category I. Head H III, his 2-3x/10’/30-35”  observation every
30 minutes  Ǿ complete, head H III-IV, his 4-5/10’/40”  second stage of
labor  the contraction was inadecuate  vacuum extraction
CASE ANALYSIS
 Case Analysis
September 27th 2017
01.30 AM
Patient come to Mutia Midwife
with abdominal contractions
Physical exam Ø 5 cm cervix
dilation
Referred due to inpartu and
history of C-section 1x
02.50 AM
Patient came to emergency room of Fatmawati
Hospital Physical exam:
• Gen. Condition : Good; LOC : CM; VS : BP :
120/80mmHg, HR : 88x/m, RR : 20x/m, T :
36,5⁰c
• Gen st : wnl
• Obs st : HIS 2-3x/10’/30-35”, FHR 132 bpm ,
Inspection Bloody show (+), Watery (+),
Inspeculo Not examined, VT Ø 9 cm cervix
dilation, head in H III, amniotic membrane (-)
Dx: Active phase of stage I on G2P1A0, 39 wga.
Singleton live head fetal presentation, prior
caesarean section 1x, interval of delivery time 5
years
 Case Analysis

03.40 AM Inadecuate 4.10 AM

Patient came to VK contraction VBAC with Vacuum
extraction
Physical exam: HIS 2- performed
3x/10’/30-35”, FHR 135 bpm,
Ø 9 cm cervix dilation, head
4.20 AM
in H III-IV, amniotic
membrane (-) • Baby girl, BW
3500 gram, BL 50
2nd stage of delivery
cm, AS 8/9
• Clear amnion,
placenta delivered
completely
 Case Analysis
Ny JL, 29 yo
Active phase of stage I on
G2P1A0, 39 wga. Singleton
live head fetal presentation,
prior caesarean section 1x,
interval of delivery time 5
years
Attempting VBAC
• VBAC indication for this
patient:
– 1x previous prior low
transverse incision
– No history of uterine rupture
– No history of CPD
– Emergency C-S team and
infrastructure available
No. Criteria Point Score Flamm-Geiger
1 Maternal age < 40 yo 2 2
VBAC score
Interpretation :
Prior vaginal delivery: Score 0-2 : VBAC success rate 42-45 %
- Prior and after caesarean section 4 Score 3 : VBAC success rate 59-60 %
Score 4 : VBAC success rate 64-67%
2 - After caesarean section 2 0 Score 5 : VBAC success rate 77-79%
- Prior caesarean section 1 Score 6 : VBAC success rate 88-89%
Score 7 : VBAC success rate 93%
- Never 0 Score 8-10: VBAC success rate 95-99%
Indication of first caesarean
3 1 1
section is not dystocia
The Flamm-Geiger VBAC
Cervical effacement
Score for this patient is 6
- > 75% 2
4 2 which is the probability of
- 25 – 75 % 1
success in these patients was
- < 25% 0 88-89%.
5 Cervical dilataion ≥ 4 cm 1 1
TOTAL 6
Weistein Factor Absent Present SCORE

VBAC Bishop score ≥4 0 4 4

SCORE Previous medical indication of prior CS 0 2 2

Grade A
Malpresentation
0 6 -
PIH (Pregnancy Induced Hypertension)
Multifetal gestation
Grade B
Placenta previa
0 5 5
Prematur labor
PROM
Grade C
Fetal distress
0 4 -
CPD or Dystocia
Umbilical cord prolapse
Grade D
Macrosomia 0 3 -
IUGR
TOTAL 11
Weistein VBAC SCORE
• Score ≥ 4 : VBAC success rate > 58% The Weistein VBAC Score for
• Score ≥ 6 : VBAC success rate > 67% this patient is 11 which is
the probability of success in
• Score ≥ 8 : VBAC success rate > 78%
these patients was 85%.
• Score ≥ 10 : VBAC success rate > 85%
• Score ≥ 12 : VBAC success rate > 88%
 Case Analysis
Attempting Vacuum Extraction
Indication of vacuum extraction for this patient is due to maternal
condition which is:
Slow progress in the second stage due to poor contraction and/or
maternal fatigue.

The requirement for vacuum extraction was fullfiled which is:

• head presentation
• head in Hodge 3-4
• amniotic membrane has broken
 SUMMARY
Attempting VBAC for delivery in this patient is
appropriate
The probability of success VBAC in these patients based
on scoring : 88-89% (Flamm-Geiger Score), >85%
(Weistein Score)
 Vacuum extraction is appropriate due to inadecuate
contraction and the requirement of vacuum was fullfiled.
THANK YOU
 References
1. Royal College of Obstetricians & Gynaecologists. Birth After Previous Caesarean Birth. RCOG Green-top Guideline no.45. 2015.
2. Cunningham, Leveno, et al chapter 30. Cesarean Delivery and Peripartum Hysterectomy: Introduction. Williams Obstetrics, 24ed. The McGraw-Hill
Companies: United States. 2014.
3. American Academy of Family Physicians. Clinical Practice Guideline: Planning for Labor and Vaginal Birth After Cesarean. AAFP guideline. 2014.
4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Birth After Previous Caesarean Section [Internet]. Australia:
RANZCOG. 2010.
5. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115. Vaginal birth after previous cesarean delivery. Obstet Gynecol.
2010;116(2):452.
6. Armstrong C. ACOG Updates Recommendations on Vaginal Birth After Previous Cesarean Delivery. J Obs & Gyn [Internet]. 2010 August: 83 (2): 215-217.
7. Mylonas I, Frlese K. Indications for and Risks of Elective Cesarean Section. Dtsch Arztebl Int 2015; 112: 489-95.
8. Dodd JM, Crowther CA, et all. Planned Elective Repeat Caesarean Section Versus Planned Vaginal Birth For Women With A Previous Caesarean Birth. The
Cochrane Collaboration. John Wiley & Sons. 2013.
9. Barber EL, Lundsber LS, Belanger K, Pettker CM, Cunai EF, Illuzi JL. Indication contributing to the increase caesarean delivery rate. Obstet Gynecol 2011;
118:29-38.
10. National Institutes of Health. National Institutes of Health Consensus Development Conference Statement vaginal birth after cesarean: new insights
March 8-10, 2010. Semin Perinatol 2010; 34:351.
11. Cunningham, Leveno, et al chapter 25. Cesarean Delivery and Peripartum Hysterectomy: Introduction. Williams Obstetrics, 23ed. The McGraw-Hill
Companies: United States. 2010
12. Royal College of Obstetricians & Gynaecologists. Operative Vaginal Delivery. RCOG Green-top Guideline no.26. 2011.
13. British Columbia Reproductive Care Program. Assisted Vaginal Birth: The Use of Forceps or Vacuum Extractor. 2001.
Q&A
 Schedule for
Antenatal Care
Uterine rupture

VBAC. Medscape 2015

 Risks of Uterine Rupture
In an unscarred
In planned VBAC In ERCS
uterus
• 2 per 10.000 • 20–50 per 10 000 • 2 per 10 000
(0.02%) deliveries (0.2–0.5%) (0.02%)
 mainly
confined to
multiparous
women in labour

Early diagnosis of uterine scar dehiscence or rupture followed by expeditious

laparotomy and neonatal resuscitation are essential to reduce associated morbidity
and mortality
It is important to note that scar dehiscence may be asymptomatic in up to 48% of
women, and the classic triad of a complete uterine may present in less than 10% of
cases
 FAILED TOLAC
• The most concerning risk of VBAC → Uterine Rupture
→ An emergency C-section is needed to prevent life-
threatening complications (heavy bleeding and
infection for the mother and brain damage for the
baby)
• Other risks of a failed TOLAC include surgical wounds,
bleeding complications that require a hysterectomy
or transfusion, and infection.
 Interpregnancy interval
• 18 months  86% success
• The rates of uterine rupture were as follows: < 12
months, 4.8%; 13 to 24 months, 2.7%; 25 to 36 months,
0.9%; and > 36 months, 0.9%.

• SOCG: Women delivering within 18 to 24 months of a

Caesarean section should be counselled about an
increased risk of uterine rupture in labour (II-2B).

The Society of Obstetricians and Gynaecologists of Can

 Sign of uterine rupture
• Frequent, strong uterine contractions, occurring more
than 5 times in every 10 minutes, and/or each
contraction lasting 60–90 seconds or longer.
• Fetal heart rate above 160 beats/minute, or below 120
beats/minute, persisting for more than 10 minutes – this
is often the earliest sign of obstruction affecting the fetus.
• Bandl’s ring formation (Figure 10.1).
• Tenderness in the lower segment of the uterus.
• Possibly also vaginal bleeding.
Factors that potentially increase the risk of uterine rupture include :
- short inter-delivery interval (less than 12 months since last delivery)
- post-date pregnancy
- maternal age of 40 years or more
- obesity,
- lower prelabour Bishop score
- macrosomia
- decreased ultrasonographic lower segment myometrial thickness.

Royal College of Obstetric and Gynecology

Comparison