OG8.10 | Post-Caesarean Pregnancy — Summary & Reflection

KEY TAKEAWAYS

Post-caesarean pregnancy management pivots on the type of previous uterine incision and a structured eligibility assessment. The key framework:

Scar types and rupture risk:
- Lower-segment transverse (LSCS) scar: TOLAC eligible if criteria met; rupture risk ~0.5%
- Classical/T/J/low-vertical scar: TOLAC absolutely contraindicated; rupture risk 4–9%

TOLAC eligibility requires ALL of: one previous LSCS, no rupture history, no absolute contraindication to vaginal delivery, adequate pelvis, singleton cephalic, 24-hour emergency CS facility

VBAC success predictors (strongest first): prior vaginal delivery > non-recurrent indication > spontaneous labour onset > favourable Bishop score > non-obese BMI > fetal weight <4 kg

Intrapartum TOLAC: continuous CTG mandatory; early rupture warning signs = inter-contraction scar tenderness + CTG abnormality + maternal haemodynamic change + haematuria + loss of fetal station; response = emergency CS

ERCS: indicated for contraindications to TOLAC or patient choice; optimal timing ≥39 weeks; cumulative risks with each repeat CS include adhesions, haemorrhage, bladder injury, and placenta accreta spectrum (up to 61% with placenta praevia after ≥4 prior CS)

Inter-delivery interval: ≥18–24 months recommended from CS to next delivery for adequate scar healing

REFLECT

Mrs Kavitha's scenario from the opening: she has one previous LSCS (lower-segment scar), a non-recurrent indication (fetal distress), an inter-delivery interval of approximately 3 years, a 3.2 mm lower uterine segment on ultrasound, and an adequate pelvis. She is eligible for TOLAC. Her VBAC success rate, based on these predictors, is moderate to good — improved if labour begins spontaneously. How would you now frame the counselling conversation for her — what probability would you give her of achieving a VBAC, and what would you say about the rupture risk in plain language? Reflect also on your institutional setting: does your current or future workplace have 24-hour emergency CS capability? How does that context shape your counselling approach for a woman in a district hospital versus a tertiary centre? What would change in your advice if she told you she wanted four children in total?