How to manage a pregnancy with a history of previous Lower Segment Caesarean Section (LSCS)?

Management of Pregnancy with Previous Lower Segment Caesarean Section (LSCS)

Women with one or two previous LSCS should be offered trial of labor after cesarean (TOLAC) as the primary option, as approximately 74% achieve successful vaginal birth after cesarean (VBAC), with maternal outcomes equal to or better than repeat cesarean delivery. 1

Key Predictors of VBAC Success

Previous vaginal delivery is the single most important predictor of successful VBAC, significantly outweighing all other factors. 1, 2

Additional favorable predictors include:

• Higher Bishop score at admission increases likelihood of successful VBAC 1
• Greater cervical dilation and labor progression at presentation 1
• Spontaneous labor onset (72% success rate) versus induced labor (63.5% success rate) 3
• Estimated fetal weight <4,000g (success decreases with macrosomia ≥4,000g) 1

Labor Induction Considerations and Risks

When induction is medically necessary, the method selection is critical due to varying uterine rupture risks:

Safe induction methods:

• Transcervical Foley catheter: No reported ruptures, preferred mechanical method 4
• Oxytocin: 1.1% rupture risk (95% CI, 0.9-1.5%) 4, 1

Higher risk methods:

• Prostaglandin E2: 2% rupture risk (95% CI, 1.1-3.5%) 4, 1

Contraindicated method:

• Misoprostol is absolutely contraindicated for cervical ripening or labor induction in women with previous cesarean delivery due to 13% rupture risk 4, 1

Women undergoing induction have significantly higher cesarean rates (36.5% vs. 28%) compared to spontaneous labor. 3

Counseling Framework

Early prenatal counseling (first trimester) should address:

• Short-term benefits: TOLAC/VBAC has equal or better maternal outcomes than repeat cesarean 4
• Short-term risks: Slightly higher perinatal mortality with TOLAC/VBAC versus elective repeat cesarean 4, 1
• Long-term benefits: Each additional cesarean increases risks of abnormal placentation (placenta previa occurs in 9,17, and 30 per 1,000 women with one, two, and three or more cesareans respectively), placenta accreta spectrum disorders, hysterectomy, and surgical complications 4
• Future fertility plans should guide decision-making 4

Absolute Contraindications to TOLAC

• Classical (vertical) uterine scar 4
• Previous uterine rupture 4
• Inter-delivery interval <18 months increases rupture risk 4
• Three or more previous cesarean deliveries (relative contraindication) 4

Intrapartum Management Requirements

Facilities attempting TOLAC must have:

• Immediate availability of surgical and anesthesia teams for emergency cesarean delivery 4
• Capability for decision-to-delivery time ≤18 minutes for suspected uterine rupture (associated with normal umbilical pH and Apgar scores >7) 4
• Outcomes worsen significantly when delivery occurs >30 minutes after suspected rupture 4

Continuous fetal monitoring is mandatory throughout labor to detect early signs of uterine rupture. 4

Common Pitfalls to Avoid

• Using misoprostol in any form for women with previous cesarean—this is associated with catastrophic uterine rupture rates 4, 1
• Failing to reassess the labor plan when patients present in active labor, as initial counseling may need revision based on presenting factors 1
• Underestimating the importance of previous vaginal delivery history—this single factor is more predictive than all other variables combined 1, 2
• Inadequate facility preparedness for emergency cesarean delivery during TOLAC attempts 4

Special Populations

Women with previous vaginal deliveries (before or after cesarean):

• Have the highest VBAC success rates among all candidates 1, 2
• Should be strongly encouraged to attempt TOLAC given excellent prognosis 2

Multiparous women with previous cesarean:

• Cesarean delivery should have a high threshold for intervention in this population 2
• Previous successful vaginal birth predicts future success regardless of intervening cesarean 2

Institutional Approach

Hospital guidelines should actively promote TOLAC/VBAC through conservative approaches to cesarean delivery, patient-specific counseling, engagement of opinion leaders, and regular auditing with physician feedback. 4

Quality metrics should track VBAC rates and maternal/neonatal outcomes to drive continuous improvement. 4