TEALE FENNING

Nick Raine-Fenning

Obstetrics 3: March 2008

What specific risks would you tell a para 1 regarding VBAC (8 marks)

What factors may influence her decision (4 marks)

What steps would you take to optimise the clinical outcome (8 marks)

premgunny · Joined: 09 Apr 2008 Posts: 16

Detailed history about indication for previous Caesarean section,details about labour events, type of incision, intra and postoperative complications other associated obbstetric problems to be elicited.
The pros and cons of both VBAC and Elective CS to be discussed. The success of VBAC(75%) is more if spontaneous onset of labour occurs.
The risk of scar rupture is 0.2-0.7% with increase maternal and perinatal morbidity and mortality.1% additional risk of blood transfusion, 1% endometritis risk, Hypoxic ischemic encephalopathy risk(8/10000), increased birth related perinatal fetal death, increased morbidity with unsuccessful VBAC however quick recovery, short hospital stay with successful VBAC.

Elective CS- no risk of scar rupture, no difference in hysterectomy, thromboembolism, anaesthetic risk,maternal death. Increase in Transient tachypnoea of newborn(3-4%), implications on future pregnancy like placenta praevia, adherent placenta, visceral injury, intensive care admission, postoperative ventilation, increase operation time and hospital stay.

Provide patient information leaflet and clear documentation in notes.

premgunny · Joined: 09 Apr 2008 Posts: 16

Personal motivation and preferences, her attitude towards rare and serious risks, plan for future pregnancy, individual chance of VBAC success rate depending upon factors like advanced maternal age,BMI>30,short stature, previous CS for dystocia/preterm, <2years from previous CS.

premgunny · Joined: 09 Apr 2008 Posts: 16

Relevant Patient information leaflet needs to be given and finalise decision at 36weeks antenatal clinic visit.
Delivery should be in suitably staffed and equipped labour ward( Obstetrics, midwife,anaesthetic,neonatal and haematology+theatre).
continuous intrapartum monitoring during established labour helps early detection and management of scar disruption by immediate laparotomy to confirm diagnosis and delivery of fetus, epidural is not contraindicated.
Women should be informed about 2-3 fold increased risk of scar disruption with induction of labour especially high with prostaglandin use, 1.5fold increase CS. Intravenous acess and full blood count and group and save at admission in esrablished labour. Careful serial cervical assessment in labour to ensure adequate progress ideally by same person and alert the team if concern.

manoj · Joined: 22 Jun 2008 Posts: 7

1. Inform the patient who want VBAC that uterine rupture is very rare but increased with VBAC(50/10,000 for VBAC vs 1/10,000 for repeat CS) and this is with one previous CS. Intrapartum infant death is rare but increased in VBAC compared with planned CS (10/10000 VBAC - same as risk for first time pregnancy vs 1/10000 for repaet CS). 1% additional of either blood transfusion/endometritis when compared with elective CS, increased risk of hypoxic ischaemic encephalopathy (8/10000 VBAC vs 0/10000 in elective CS). VBAC carries reduced risk with respiratory problem in newborn rates 2-3% for VBAC and 3-4% for repeat CS. If having induction of labour will inform increased risk of uterine rupture with prostaglandins is 2-3fold over the above risk. similar risk for planned VBAC for preterm but with lower risk for uterine rupture.

2. Delivery should be adviced in consultant led unit with immediate access to CS and blood transfusion and so this will influence her decision on place of delivery, other factors are previous surgeries like more than 2 previous CS, classical CS, T or J shaped previous uterine incision or major uterine surgeries like myomectomy involving full entry into uterine cavity are strongly advised against vaginal delivery as significant increased risk of uterine rupture. Women opting VBAC will need continous EFM in labour for early prediction of fetal distress(possible scar dehiscence /uterine rupture sign) and may influence with patient choices like pool birth. Current pregnancy absolute indications for CS like breech presentation (ECV failed/declined/contraindicated), twin with presenting breech, HIV,Major placenta previa will also influence her option for decision.

3. Antenatally well planned documented care ideally all plans by 36 weeks gestation and placental location same time and if suspicious of accreta for further Colour Doppler or higher centre referral, informed choice of patient well documented and written information provided to the patient regarding VBAC options. Intrapartum clinical care as above delivery in consultant led unit with continous EFM monitoring and immediate access to CS and blood transfusion, immediate access for neonatologist, adequate staffing on labour ward and one to one care in labour with doctors input in labour with consultant supervision IV acess in labour.
Active management of third stage of labour to minimise blood loss. (do we have to write about uterine inversion here or not? /probably not)
Proper debrief to patent regarding delivery, future plans for pregnancy and delivery options, contraception and correspondence to GP.

shachi · Joined: 10 Jun 2008 Posts: 16

Vow......Impressive!
However I dont believe that breech with failed ECV, HIV or twins with breech twin 1 are absolute indications of CS.
Its all about patient choice (INFORMED of course).......remember!

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 946

hi guys,

a very good attempt indeed.

i do agree with sachi about the absolute contraindiacation comment,

for me absolute would be, central PP, classical CS, myomectyomy scar where ut cavity was opened, hydrocephalus in the baby ( that too depends on the multi disc input advice ) etc.

relative would be poly hydramnios, twins, IUGR, breech etc... this is where the obstetrician will feel safe with a LSCS, but the decision has to come from the patient --- 'informed choice'

the bee in my bonnet is -----

you mention failed ECV as an absolute CI for VBAC. Will you offer ECV for breech on an already scarred uterus???

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

manoj · Joined: 22 Jun 2008 Posts: 7

you are right I would not offer ECV with previous scarred uterus as there is very little evidence to support this but could also be argued by people who offer ECV in this group of patients, that there is no evidence of extra harm in offering, I might be wrong open for discussion.

shachi · Joined: 10 Jun 2008 Posts: 16

I would offer ECV in scarred uterus. I know at least 2 units who do:
PAH, southampton
Cardiff
BTW Raj, Cant you chill a bit even in ur annual leave?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 946

hey,

haven't you heard ???

the brain is a muscle, don't excersise it and get alzheimer's!!!

and what can i say i am gulity of taking O&G seriously!

Laughing

r

p.s--- study harder, 51 days to the exam.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Abik · Posted: Wed Aug 20, 2008 8:24 pm Post subject:

I would also offer ECV with a scarred uterus, In fact, I can't think of anyone I wouldn't offer ECV to (singleton breech) - I suppose those who you're going to do a section on anyway.