TEALE FENNING

m.karoshi · Joined: 24 Oct 2006 Posts: 11

Dear all

I have a scenario wherein patient has had a caesarean section at 40/40 at full dilatation 2 years ago for failure to progress and baby weighed 3.8Kg

Now she is 38/40 weeks and had a scan which shows expected birth weight of 4Kgs and her GTT at 26 weeks is normal. She is very keen for vaginal delivery and is concerned that if she weights another 2 weeks, baby will grow big and her plan of vaginal delivery may not be successful, hence she wants IOL now.

Nick Raine-Fenning · Posted: Thu Nov 09, 2006 11:01 am Post subject:

It's a good question and there are several issues here.

Estimated fetal weight

Notoriously difficult and inaccurate on the whole (maybe a little better than it was but there is still a degree of error) plus EFW has limited if any predicitve value in terms of achieving a normal delivery. Obviously if the fetus is very macrosomic (4.5kg) or, worse still, asymmetrically macrosomic then the chance of a nornal delivery falls plus the risk of shoulder dystocia increases.

Past Obstetric History

What was the section for? There is no real evidence but you may be more concerned about the woman that labours spontaneously and then progresses normally only to have a secondary arrest in the first or, as i the this case and worse still, second stage. What if she had had a failed forceps in the room or in theatre?

Induction

As far as I am aware the best way to achieve a normal delivery after previous CS is to labour spontaneously. If I am right induction is actually associated with a reduced chance of spontaneous delivery, an increased risk of instrumental delivery and caesrean section, and shoulder dystocia. Induction is not without risk as you know so you would also need to discuss the increased need for analgesia and scar dehiscience.

Gestational Age

Fetal growth slows dramatically near term - look at the growth charts. Waiting 2-3 weeks is unlikely to result in a significantly larger fetus.

The GTT

Why did she have this? The fetal weight alone is not a sufficient indication. The fact it was normal (and depending on the indication it may need repeating) is actually reassuring as the fetus has a lower chance of being stillborn which is something that increases week by week after 40 weeks according to the Cochrane Database and Effective Care.

So in summary, induction is not without risk and is probably the worse thing to offer her if she really wants a normal delivery. Some argue you should wait for the spontaneous onset of labour and consider elective caesrean if she does not labour.

Remember if the patient demands this in the role play you must start by agreeing, in principle, to her wishes. You then use the Teale Fenning "four step process" to advise her. Who wants to tell me what the "four step process" involves in this case?

Rolling Eyes

_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

m.karoshi · Joined: 24 Oct 2006 Posts: 11

1.What is good about what patient wants?

2.What is bad about what patient wants?

3.What is good about what (dr) suggests?

4. What is bad about what (dr) suggests?

Am I right?

Nick Raine-Fenning · Posted: Fri Nov 10, 2006 8:44 am Post subject:

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

hey nick,

tried this in the clinic yesterday on a very very very difficult patient.....

works a treat! Laughing

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

Nick Raine-Fenning · Posted: Sat Mar 10, 2007 11:16 am Post subject:

Of course ... good to hear. Smile

_________________
"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Abik · Posted: Mon Apr 02, 2007 6:18 pm Post subject:

This is everyones bread and butter ANC patient.

I would love to be an examiner and hear what we all come out with for scenarios like this one!!!

The fact that she wants a vaginal delivery is a heaven send as from here you can reassure her that this will be the best outcome and her chances of success are around 50%. (I can't believe it's that low but there you go!)
I would agree with her that it seems logical that to deliver the baby earlier would result in a smaller baby and that this might increase her chances of delivery but that actually there is no evidence to support this. (see Nicks note on growth and accuracy of USS)

What we do have evidence on is the increased risks associated with IOL including failure and scar rupture.

It is useful to know the reason for LSCS at full dilatation - likeliest to be malpresentation and a multips uterus is more likely to overcome this. I think that failed instrumental is more likely down to operator inexperience than true CPD - if it was truely felt to be deliverable vaginally then it should have been!!!!!!!!!! Wink

Nick Raine-Fenning · Posted: Tue Apr 03, 2007 11:06 am Post subject: