Clinical and Ultrasound Score for Evaluation of Previous Cesarean Section Scar
Condition: Previous Cesarean Section Scar
Study type: Interventional

Summary: 
      Cesarean delivery rates have increased dramatically worldwide. In the United States, cesarean
      section (CS) rates increased from 5% of all deliveries in 1970 to a high of 31.9% in
      2016.Although efforts were made to reduce the number of CS, it failed to achieve the 15% rate
      recommended by the World Health Organization (WHO).Repeat CS is the most significant factor
      contributing to overall increased CS rates. The primary indication of repeat CS is a prior
      CS. The trial of labor after cesarean (TOLAC) is an attempt to reduce CS rates. Several
      national medical associations have provided practice guidelines for vaginal birth after
      cesarean section (VBAC), but these differ across countries.VBAC is relatively safe when
      compared with repeat CS.However, TOLAC rates have dropped significantly worldwide in recent
      years.
    

Detailed description: 
      Brief History taking include: age of patient, gravidity, parity, time interval between
      previous cesarean sections and current pregnancy, indication for the previous cesarean
      section, and fetal weight of previous delivery with special emphasis on menstrual history for
      proper dating and history of previous pregnancy to verify the inclusion or exclusion
      criteria.Physical examination include : General examination: for exclusion of presence of any
      medical disorders,Obstetric examination include: Fundal level to correlate with gestational
      age known by history, Umbilical grip to verify inclusion and exclusion criteria, Scar
      tenderness and shape in women who had undergone a previous cesarean section and
      investigations that will be performed including the following:basic routine antenatal
      investigations of pregnant women including blood group,Rhesus factor, complete blood count,
      blood sugar, and urine analysis. abdominal and transvaginal ultrasound will be performed
      for:a complete obstetric assessment at full term using TAS to confirm gestational age, fetal
      vitality, lie and presentation, amniotic fluid and placental position.Evaluation of the lower
      uterine segment using TVS, by measuring its thickness and identifying the echo structure for
      beinghomogenous or not . The LUS will be visualized in the sagittal section in the midline
      and lateral plane. The measurement will be obtained with the cursors at the urinary bladder
      wall- myometrium interface and the myometrium chorioamniotic membrane-amniotic fluid
      interface. Three layers can be identified by ultrasonography in a well-developed LUS in a
      midline section of sagittal view in a partially filled bladder. They are as follows from
      inside outwards:Chorioamniotic membrane with decidualized endometrium, a middle layer of
      myometrium and utero-vesical peritoneal reflection juxtaposed to muscularis and mucosa of the
      bladder.The lower uterine segment will be visualized in sagittal section in the midline.There
      after :150 patients will be evaluated using a measurement value of the clinical and
      ultrasound criteria and Follow up of all participants will be followed up till delivery, the
      mode of delivery either VBAC or elective repeated lower segment CS according to:History and
      clinical examination evaluation: Previous complicated CS or not, time interval between
      previous cesarean sections and current pregnancy(less than one year or more than one
      year),tender scar or not. US : TAS and TVS include: Lower uterine segment thickness , The
      echo structure of the lower uterine segment (Homogenous or nonHomogenous). For follow up of
      patient with previous CS include Initial evaluation: Each of the clinical and US parameters
      will be scored based on the sum of points is shown in table whatever to complete delivery by
      natural means or again by cesarean section.If the score is more than 7 out of 10 a vaginal
      birth will tried. On the other hand,Score 7 or less than 7 will be considered an indication
      to do repeated elective cesarean section.Careful follow up of patient during trial of labor
      after CS [TOLAC] for any possible symptoms and signs of uterine rupture that require
      immediate surgical intervention like : bleeding either intra abdominal or vaginal,cessation
      of uterine contraction,abnormal uterine contour,abdominal distention,shoulder tip
      pain,supraoubic pain,sudden severe abdominal pain may decrease after rupture,tender
      abdomen,rapid materinal pulse, low blood pressure,hypovolomic shock if rupture involve major
      blood vessels,no fetal presentation on vaginal examination,prolonged fetal bradycardia and
      absent fetal heart activity during continuous electronic heart rate monitoring.Careful
      examination of patient after vaginal delivery to detect any maternal complication by: local
      examination under anesthesia to ensure continuity of cesarean scar and ultrasound evaluation
      of scar.The parameters that are evaluated by clinical and ultrasound criteria Clinical and
      ultrasound criteria SCORE (2) SCORE (1)Tender scar Not tender (2) Tender (1)Previous
      complicated CS Not complicated (2) Complicated (1) ,Echo structure of the LUS Homogenous (2)
      Non homogenous (1)Lower uterine segment thickness More than or equal 3.65 mm(2) .more than
      3mm to less than 3.65 mm(1)Pregnancy time interval after the CS More than 12 months(2) 12
      months or less(1)Total Score (10) (5)
    

Intervention name(s): Trial of labor after cesarean section
Intervention type(s): Procedure
Intervention description(s): The pregnant females with history of previous cesarean section will be classified according to clinical and ultrasound score as patient suitable to undergo trial of labor after CS [TOLAC]or not suitable for [TOLAC] so undergo from the beginning to elective repeated cesarean section.
Other intervention name(s): Elective repeated cesarean section
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Prevention
Keywords: Trial of labor after cesarean section(TOLAC)& vaginal birth after cesarean section (VBAC)