Pregnancy After C-Section: Dos & Don'ts

The surgical procedure involving incision of the abdominal wall and the uterus in order to bring out the baby is termed as Caesarean Section. Globally there’s a rising trend of Caesarean Delivery with prevalence in the western world of 25 to 30 per cent of all deliveries. As per the National Family Health Survey of India year 2019-2021 Caesarean Delivery has risen to 21.5 per cent from the previous study year 1998-1999 of 16.72 per cent. Better education, wealth, good partner support, late child-bearing, small family norms, Obesity, rising medicolegal issues, are all contributory factors to this change. Hence we now see more pregnancies post Cesarean which fall into high risk category and demand special care.

Pregnancy after Caesarean Section - Risks:

1. Placenta Previa wherein the placenta is low in its attachment to the uterus and Placenta Accreta which is placenta that has embedded deeper into the uterine musculature are known risks of future pregnancy, carrying a risk of 10:1000 after 1 previous Cesarean & 28:1000 after 3 or more previous Caesarean, as compared to 4:1000 for the general population of pregnant women. Both conditions increase maternal morbidity & mortality through haemorrhage and it’s consequences.
2. Uterine rupture wherein the previous scar gives way during pregnancy or more often during labour. This is seen during Trial Of Labour After Caesarean (TOLAC). Risk depends  on factors such as the number of previous Caesarean sections, the type of Caesarean Section cut - Tranverse or Vertical cut, the area of the uterine incision - Upper segment (Classical / Hysterotomy) or the more frequent lower segment and the inter pregnancy duration. Least risk is involved when there’s a single transverse lower segment incision - 0.5% chance of rupture. Whereas the upper segment Classical incision and multiple previous Ceasarean carry high risk of rupture thus not permitting TOLAC. Also spontaneous labour carries a lower risk for attempting vaginal birth after Caesarean (VBAC) as compared to Induced & Augmentation of labour that increases the risk of Uterine rupture 3 times.
3. Niche or Isthmocoele formation and Uteroperitoneal fistula formation at scar.
4. Unexplained Stillbirth has been reported at increased risk especially beyond 39 weeks.
5. Preterm birth risk - 12 per cent increase compared to previous vaginal delivery. Risk is more if the previous Caesarean was done in the second stage of labour, low incision.

How long to wait after Caesarean section?

The uterine scar needs a minimum 18 months to regenerate and gain adequate strength. Studies have shown that in short inter pregnancy interval of < 6 months the subsequent pregnancy carries a higher risk of uterine rupture 2-3 per cent as compared to 0.5 per cent.

What to expect?

Vaginal Birth after Caesarean(VBAC) or Elective Repeat Caesarean Section(ERCS) are the  2 modes of delivery. Decision making regarding the mode of delivery is discussed during antenatal period sometime after the mid trimester ultrasound is done. In most the decision should be finalised by 36 weeks and best documented for reference.

VBAC being best suited for women with a 37+ week singleton pregnancy with cephalic presentation & a single previous lower segment Caesarean section with or without a previous vaginal delivery. Planned VBAC has a success rate of 72-75%, while it carries a risk of uterine rupture at 0.5 per cent. A previous vaginal delivery increases the success for VBAC and decreases chance of uterine rupture. Spontaneous labour show better outcomes & lower risk of uterine rupture compared to Induction & Augmentation. BMI <30, gestation <40 weeks, maternal age <40  and infant birthweight <4kg have better success for VBAC.

ERCS is best planned at 39+ weeks but may change if patient goes in labour earlier. ERCS has very low risk of rupture 0.02% but a longer recovery with future increased risk of Placenta Previa / Accreta. ERCS can reduce risk of pelvic organ prolapse & urinary incontinence. Sterilisation procedure can be done if patient demands along with. Risk of transient respiratory morbidity in neonate following ERCS is 4-5 per cent. if performed at 38 weeks and can be prevented by antenatal corticosteroids to mother though long term implications need consideration. Risk of maternal mortality is 13/100,000 & of perinatal death & Hypoxic Ischaemic Encephalopathy is low at <0.01 per cent.

Contraindication to VBAC is previous uterine rupture, Placenta Previa and prior Classical Ceasrean section. Placenta Accreta an adherent placenta with abnormal growth into the musculature of Uterus occurs in 11-14 per cent of women with placenta previa & 1 prior Caesarean delivery & in 23-40 per cent with placenta previa & 2 prior Caesarean deliveries.

VBAC is best conducted in a well staffed delivery suite with continuous intrapartum monitoring   and resources for immediate Caserean daelivery and neonatal resuscitation in event of complications.

Nine Tips for Quick Recovery:

For Enhanced Recovery After Caesarean Section Guidelines are summarised below-

1. Skin to skin contact of baby with Mother at birth for better bonding.
2. Maternal monitoring of Vitals, Uterine tone, vaginal or incisional bleeding, urine output amongst the Maternal Early Warning Signs.
3. Early Feeding - Chewing gum for 15 mins at least 3 times a day or sham feeding & oral liquid & soft diet in 2 hours helps prevent nausea & vomiting & enhances bowel recovery.
4. Nausea & Vomiting prevention with anti-emetics & antacids to dilute the acidic gastric juices.
5. Pain management with analgesics like Acetaminophen, Non Steroidal Anti Inflammatory Drugs(NSAIDs).
6. Thrombo prophylaxis by means of pneumatic compression device, stockings, medications like low molecular weight Heparin given 6-12 hours post surgery in order to prevent venous thromboembolism(VTE) especially in the obese or those with Inherited thrombophilias or previous venous thromboembolism.
7. Early ambulation within 4 hrs helps, with 5-10 mins of activity 4 times a day. This not only prevents VTE but helps in early bowel movement too.
8. Urinary Catheter can be removed as early preferably within 6 hours.
9. Discharge advice - Avoid lifting heavy weights above 6 kg. Kegel’s pelvic floor exercise soon after & 4-6 weeks later aerobics and abdomen strengthening exercises in a step-wise fashion. Dressing may be removed after 48 hours or  the wound cleaned and bath can be taken. Contraception counselling. Resuming sexual activity after 6 weeks. Sutures if need to be removed can be done after 7-10 days.