TRIAL OF SCAR

MDS 2 2019 COHORT

PRESENTED BY M.JONAZI
22/02//2023
Learning Objectives
By the end of the lesson, you should be able to:
1. Define trial of scar
2. Describe contraindications for Trial of scar
3. Explain the complications and dangers of Trial of scar
4. Describe the prerequisites for Trial of scar
5. Explain the management of Trial of scar
Definition

• Term given to a labour where a vaginal delivery is

attempted when the woman has had a previous
Caesarean section
• Trial of scar came into favour with the introduction of
the transverse incision of the lower uterine segment.
Controversies to trial of car
• One can never be certain of the integrity of a
previous scar and there is no reliable means of
evaluating the strength of the scar before the onset
of labour
Cont’
• Whether a woman undergoing a trial of scar should
be given epidural analgesia.
Ø epidural analgesia relives the pain of labour,
allows for palpation of the scar in labour and
puerperium, for signs of rupture; less inco-ordinate
uterine action:
Controversies to trial of car
Epidural analgesia
Others say the epidural masks pain, scar may rupture
and the woman does not experience a tearing pain,
rupture of the uterus with blood loss and shock , is
difficult to treat if there is also hypotension from the
epidural.
Contraindications to Trial of scar
• Previous hysterotomy
• Previous myomectomy
• Cornual resection
• Repaired uterine rupture
• Cardiac disease
• Contracted pelvis or any other form of cephalo-pelvis
disproportion
Contraindications cont’
• Malpresentations: breech, brow, face, oblique or
transverse lie.
• Previous vertical(classical) incision of the uterus
• Multiple pregnancy
Conditions where Trial of scar may be
attempted
• When there has been a previous lower segment
transverse incision of the uterus only
• An active labour with progress, in a previous labour ,
which resulted in a Caesarean section for anything
other than CPD
Cont’
• If there has already been a previous vaginal birth
• Where there is an engaged head confirmed at the
onset of labour
• A ripe cervix and a spontaneous onset of labour
Complications and dangers
• Rupture of the uterus at the site of the scar
• Postpartum haemorrhage
• Foetal asphyxia
• Perirectal abscess, possibly from previous adhesions
and infection
• Wound defect
• Postpartum bladder atony , due to previous
adhesions.
Prerequisites for Trial of scar
• No additional indication for Caesarean section in the
current pregnancy( for example CPD
• There must be access to documentation of previous
labours and Caesarean section
• Early admission for preparation
Cont’
• Two units of blood
• Facility must be available and in readiness for
immediate Caesarean section ( within 15 minutes)
• Careful counselling, fully informed and consent
Prerequisites cont’
• Intravenous infusion of 5% dextrose/water at the onset
of labour
• Onset of labour should be spontaneous
• Continuous foetal monitoring
• Make sure second stage of labour is not prolonged,
vacuum extraction in readiness by the Doctor
• The Doctor will have to do an evaluation of the uterine
scar during labour and also after the delivery.
Midwifery and Obstetric management
Together with standard care for a woman in labour, the
following specific care is given:
• The woman is fully informed
• Not allowed to eat and /or drink during labour
• Collect blood samples for Haemoglobin. Grouping and Cross
matching
• Intravenous therapy is put up using 5% dextrose/water
• Two hourly voiding of urine is encouraged
Midwifery and Obstetric management
• Resuscitative equipment ready for the mother and
baby
• Careful observations for pain: type, frequency and
site to detect the first signs of uterine rupture
• Labour must not be allowed to become prolonged at
any stage
First signs of slow progress are reported to the
doctor immediately.
Cont’
• Careful vaginal examinations by the Doctor . Attempt
should be made to palpate the scar
• Support, reassurance and encouragement are given
at all times
• The mother and her family are kept fully informed
of the progress of labour.
Reference
Sellers P.M.(2011). MIDWIFERY VOLUME 2. Lansdowne:
Juta and Co, Ltd.