TEALE FENNING

Xerxes I

This is a patient I had today.

8 weeks pregnant, previous 3 CSs, in the last CS very thin lower segment was noted. Was asking if I would advise a TOP. I will give more info and tell you what sort of questions they were asking as we discuss.

Just to make it worse, her previous obstetric notes were not available!, the Consultant was not there and the husband was a very big and angry man!!, fortunately this does not happen in the OSCE, I mean at least a consultant is there in the room Smile

.

bronwyn · Posted: Fri Apr 13, 2007 4:44 pm Post subject:

hadeeha....the friday morning, wednesday afternoon absent consultant scenario......I used to take a "to discuss with the boss" list to theatre with me on a monday Wink

How did u know she had a thin lower segment if you didn't have previous obstetric notes?
Good case to discuss though.
Did you offer the big angry husband a vasectomy?
B
_________________
Bronwyn Bell
SpR
Portsmouth

Xerxes I · Posted: Fri Apr 13, 2007 5:36 pm Post subject:

Yep, exactly. That's my inheritence.

They were told by the surgeon at the time of CS but no comments on what they should do next time and more importantly no vasectomy for the big angry husband at that time. Great debriefing.

When they left, her notes arrived, typical!, they had mentioned: "very thin lower segment, had to close in one layer".

Good point though about vasectomy. This certainly gets a tick mark if mentioned tactfully and at the right time.

like so: why did you get pregnant again?, did they not talk to you about contraception? impossible. I am sure they have said something and you don't remember. Or may be they were busy, I will find out for you who that person was. never mind, but why did your GP not mention anything? pufff. I think you should have a vasectomy. Laughing

Well, my consultation wasn't much better than this, they didn't leave happy as after a long consultation the verdict was "I will see your notes, talk to the boss and contact you on Monday". somebody heard the husband say "waste of time" in the corridor!

Later in the clinic the MCA goes: Bronwyn was a very nice lady!!!

Nick Raine-Fenning · Posted: Fri Apr 13, 2007 8:21 pm Post subject:

This is a great example of what you could expect in the OSCE in one form or another. The key is to approach them all the same.

You can't lose as you do not need to make a decision. I guess you do not need to until you are the boss and you can worry about that then!

Basically play to the rules - tell them the risks and explain that these are not readily predictable. If she labours she has a very high risk of uterine rupture and fetal death. However she could get to term and have an uneventful caesarean. It may be sensible to offer earlier delivery but this has to be balanced against the problems associated with iatrogenic prematurity.

TOP is not without risk although she will not have a lower segment at this stage. It is a valid option therefore.

Contraception must be discussed in either situation and include a full run down of male and female options remembering there is no gold standard.

Done!

You have covered the options. Give them the ever essential info leaflets and other reference material such as web links and allow them time to consider their options. They can come back when fully aware and see the boss then! No need for a list or phone call.

You have been just as useless but you may avoid the 'waste of time' comment and most importantly get a good score on that station. Very Happy

I do not think you can categorically advise against pregnancy continuation unless there is no lower segment or an untoward past obs history. I've seen, and I am sure you have, paper thin lower segments with holes in them and fetal bits sticking out and you have never have known from the patient, partogram, or CTG!
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wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Rupture occurs only if she goes into labour therefore TOP should not be adviced on that basis but I would certainly discuss TOP as it might be wanted for other reasons! (why the husband is so angry?).
An elective C/S at 38 weeks is a good idea balanced against risks for TTN/RDS.
The angry husband... Domestic violence issues? (I still cannot recover from the written part..).

Xerxes I · Posted: Sat Apr 14, 2007 9:57 am Post subject:

Thanx Nick.

Wolverine, I think you are absoloutely right in searching for hidden agenda. My feeling during the consultation was that they wanted me to advise them to have a TOP. They had come to hear that to be able to tell themselves, well the doctor said we should terminate it. I obviously could not do that and it was one of the reasons (and me being crap!) they weren't happy.

What would you do if they want to hear figures and numbers? I mean in this case the husband wanted to know what is the risk of the uterine rupture or dehiscence prior to labour was.

The other trap I fell into was the placental site, placenta accreta etc. this took us into a long discussion about risks and then came caesarean hysterectomy.

It was a nightmare.

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

I don't know the exact figures but it is very unlikely to rupture without contractions and that's what I would tell them.
As regards to the placenta site I would have waited for the scan (as the risk is still quite low I think 2% for the fourth C/S?) and then discuss it if it is suggested from the scan

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Still I can recall this figure, risk of scar dehiscence is about 0.5%, however, this figure will goes up with increasing number of scars, decrease duration interval between pregnancy, overdistension of uterus, etc.

I think there is antenatal rupture [ silent rupture ]
I saw uterine rupture at 35 weeks in patient with previos 3 CS which was fresh rupture and the baby can be saved with the help of God, and it was a male baby with good condition and she had previuosly 3 females,, the uterus had been repared and TL is done.

The mother was unhappy from me and from her male baby....
I thought at that time that she might have post natal depression, hypothyroidism may be....

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

as wolverine said, and me;
0.5-2%

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

the scar figures i remember are...

1 LSCS -- 0.5%

2 LSCS -- 4%

3 LSCS -- 12%

4 LSCS 25%

don't remember where these r from but have always known them. Smile

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

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

hi all,

some other figures i found are...

1x previous LSCS + spontaneous labour -- 0.5%
1x previous LSCS + IOL without prostaglandins -- 0.8%
1 x previous LSCS + IOL with prostaglandins -- 2.5%
1x previous classical CS -- 4-9%

ref --

Guise JM, Berlin M et al. Safety of vaginal birth after cesarean: a systematic review. Obstetrics and Gynecology 2004 Mar;103(3):420-9.

Lydon-Rochelle M, Holt VL et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001 Jul 5;345(1):3-8.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Hi all! All these figures might be correct but only during labour. It's highly unlikely that any scar would rupture spontaneously.
My 2% figure was the likelyhood for a placenta praevia in a subsequent pregnancy (after 4 scars)

bronwyn · Posted: Wed Apr 18, 2007 8:30 pm Post subject:

Wolverine,
Incidence of placenta praevia following
1 LSCS is 0.65% (accreta's in praevias 24%)
2 LSCS is 1.8% (accreta's in praevias 47 %)
3 LSCS is 3% (accreta's in praevias 40%)
4 LSCS is 10% (accreta's in praevias 67%)

from Luesley and Baker

A multivariable analysis of the NICHD study showed that there was no significant difference in the
rates of uterine rupture in VBAC with two or more previous caesarean births (9/975, 92/10,000)
compared with a single previous caesarean birth (115/16,915, 68/10,000).

B
_________________
Bronwyn Bell
SpR
Portsmouth

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Thanks Bron! I meant placenta acreta not placenta praevia.

Abik · Posted: Sun Apr 22, 2007 8:36 pm Post subject:

Great question.

Is there any difference in counselling this woman compared to anyone else with previous caesareans? The "thin segment" is irrelevant isn't it?

I'm not sure why this couple thought that termination was justified. I guess you could tell them that it's no more necessary than with their last child who was the third caesarean!

That study about no difference in rupture risk has to be rubbish - 16000 versus 975!! Do me a favour! More CS MUST equal more risk, just cos we haven't proved it yet!!

Laughing

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

The few studies that adress this issue are
1)Miller DA, Diaz FG, Paul RH. Vaginal birth after cesarean: a 10-year experience. Obstet Gynecol 1994;84:255-258

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

http://www.emedicine.com/med/topic3434.htm

http://www.motherfriendly.org/Downloads/csec-fact-sheet.pdf- This article seems to have good points taht can be used in counselling.

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

To sum up

1 x previous LSCS + repeat C section -- 0.16%
1 x previous LSCS + spontaneous labour -- 0.5%
1 x previous LSCS + IOL without prostaglandins -- 0.8%
1 x previous LSCS + IOL with prostaglandins -- 2.5%
1 x previous classical CS -- 4-9%

2x previous LSCS + spontaneous labor-- 1-3.7%