PREDICTIVE VALUE OF INTRAPARTUM

PARTOGRAM
TO
ASSESS FOR SAFE VAGINAL
DELIVERY
AFTER
PREVIOUS
CAESAREAN
SECTION.
Dr. Aanchal Sablok , Dr Achla Batra
Senior Resident , Professor and Consultant
Department of Obstetrics & Gynaecology,
Vardhaman
Mahavir
Medical
College
Safdarjung Hospital,
Delhi

&

INTRODUCTION

Management of labour in women with

previous caesarean section poses a
decision-making
challenge
to
the
obstetrician
with
regards
to
continuation or termination of trial of
labour.

With proper selection and good

management of labour, vaginal birth
after caesarean section is safe.

An easily performed and reliable intra-partum

method of assessment of these patients is
essential to predict the outcome of labour
accurately.

The partogram has improved the quality of

obstetric care the world over, has been found
to give early warning of abnormal progress in
labour, and has assisted obstetricians to
make appropriate decisions for intervention.

AIM OF STUDY

It is against this background that this

study was conceived, to assess the
predictive value of the partogram in
the management of vaginal birth after
a previous caesarean section.

PATIENTS AND METHODS

Prospective study conducted on 100

women with one previous caesarean
section, with or without previous vaginal
birth, who were managed in the labour
ward of the Safdarjung Hospital &
VMMC, Delhi.

Study period: 1st july, 2015 to 31st

Dec., 2015.

SELECTION CRITERION

INCLUSION CRITERIA
Single previous lower
uterine
segment
caesarean section.
Presented
in
labour
after
34
weeks
gestation.
Singleton pregnancy.
Fetus
in
vertex
presentation
with
reactive fetal heart rate.

EXCLUSION CRITERIA
Women with more than
one
previous
lower
segment
caesarean
section.
Previous
classical
or
inverted T-incision.
Carrying
multiple
pregnancy.
H/O medical disorders.
Presented at or before 34
weeks gestation.

At presentation, women confirmed to be in active

phase of labour, taken as dilatation of at least 4 cm,
transferred into the labour ward, progress of labour
recorded on a WHO partogram.

Alert line plotted as 1 cm cervical dilatation per hour

from the point of admission, while action line plotted
2 h to right of alert line.

Cervical dilatation and descent of the fetal head

assessed every 2 h and plotted on partogram.

Maternal and fetal physiology assessed and plotted

regularly on partogram.

Women with inefficient uterine action, after

excluding cephalo pelvic disproportion,
oxytocin infusion initiated and titrated.

Scar tenderness, vaginal bleeding more than

show, and presence of haematuria used to
assess integrity of uterine scar.

These observations continued till full cervical

dilatation or delivery of the baby, or when trial
of labour abandoned for caesarean section.

Cervical dilatation rate (CDR): cervical

dilatation in centimeters (cm) achieved between
observations divided by time in hours that was
taken to achieve it.

Average cervical dilatation rate (ACDR):

final cervical dilatation in cm(s) achieved
divided by time in hours that taken to achieve it.

The duration, progress and outcome of labour

recorded.

STATISTICAL ANALYSIS

Simple percentages were used to describe categorical

variables.

Quantitative variables were summarised using mean

and standard deviation.

The Z-test was used to test for significant differences

between means.

A p value
significant.

Measures of validity were computed for predictors.

of

0.05 was

considered

statistically

RESULTS

A total of 100 women with a previous

caesarean section who met the
inclusion criteria recruited for this study.

29

71

Normal vaginal
delivery
Repeat Caesarean
Scetion

Vaginal
delivery
(n=71)

Repeat
Caesarean
section
(n=29)

Test and
p value

Mean Cervical
dilatation rate
(cm/hr)

0.69 0.13

0.290.18

Z=6.79
p=0.0002

Mean average
cervical
dilatation rate
(cm/hr)

1.17 0.43

0.2 0.19

Z=3.27
p=0.001

Predictive value of CDR on the outcome

of labour in vaginal birth after
caesarean section (VBACS).
Cervical
dilatation rate
(CDR) (cm/h)

Vaginal
delivery
(n=71)

Repeat
caesarean
section
(n=29)

Total

< 0.5

5 (22.8%)

17 (77.3%)

22 (100%)

0.5 - 1

41 (78.9%)

11 (21.2%)

52 (100%)

>1

25 (96.2%)

1 (3.8%)

26 (100%)

CDR 0.5 cm/h had 92.9% sensitivity,

58.6% specificity and PPV of 84.6%.
CDR 1cm/h had 35.2% sensitivity, 96.6%
specificity and PPV of 96.2%.

Predictive value of ACDR on the outcome of

labour in vaginal birth after caesarean section
(VBACS).
Average
Cervical
dilatation rate
(ACDR) (cm/h)

Vaginal
delivery
(n=71)

Repeat
caesarean
section (n=29)

Total

< 0.5

3 (17.6%)

14 (82.4%)

17 (100%)

0.5 - 1

39 (73.6%)

14 (26.4%)

53 (100%)

>1

29 (96.7%)

1 (3.3%)

30 (100%)

ACDR 0.5cm/h had 95.8%

specificity and PPV of 81.9%.

sensitivity,

51.8%

ACDR 1cm/h had 40.8% sensitivity, 96.6% specificity

and PPV of 96.7% for predicting a normal vaginal delivery.

Predictive value of alert line on the

outcome of labour in vaginal birth after
caesarean section (VBACS).
Alert Line

Vaginal
delivery
(n=71)

Repeat
Caesarean
section
(n=29)

Total

Crossed

6 (17.7%)

28 (82.4%)

34 (100%)

Not crossed

65 (98.5%)

1 (1.5%)

66 (100%)

Crossing alert line had 91.5%

sensitivity, 96.6% specificity and PPV of
98.5%.

There was no scar rupture.

Feto maternal morbidity were minimal (mild

birth asphyxia, puerperal pyrexia from wound
sepsis) and these were similar in the two groups.

There was no maternal or perinatal mortality.

The mean birth weight of the babies (repeat

caesarean section 2.38+0.37 kg and vaginal
delivery 2.34+0.41 kg) were similar in the two
groups.

DISCUSSION

Successful vaginal delivery rate was 71% in this

study.

Recurrent indications for previous caesarean

section not included in the exclusion criteria,
because some of caesarean sections done
because of obstetrician distress, financial reasons
or lack of labour monitoring facilities.

Mean CDR, and mean ACDR both showed

statistically
significant
differences
between
women who had vaginal delivery and those who
had repeat caesarean section.

Could be due to better descent and application of

fetal head to cervix, stimulating cervico uterine
reflex with resultant stronger and more
coordinated uterine contractions, and faster rates
of cervical dilatation among those women who
had successful vaginal delivery.

Accounted for higher vaginal delivery rate among

women with CDR 1.0 cm/h & ACDR 0.5 cm/h, and
higher repeat caesarean section rate among
those with lesser rates of cervical dilatation.

CONCLUSIONS &
RECOMMENDATIONS

CDR, ACDR and alert line helps obstetrician to identify

women who are high-risk cases and may require
intervention.

Action line plotted 2 hr to right of alert line instead of

usual 4 hr for purpose of monitoring labour in women
with previous caesarean section, reduce incidence of
rupture of uterus without unacceptable increase in
caesarean section rate.

Intra-partum Partogram can go a long way in

management of patients with history of previous
caesarean section and facilitate safe vaginal delivery
in this cohort.

Thank you!!