TEALE FENNING

docsubhi · Joined: 03 Sep 2007 Posts: 51 Location: london

Options for Questions 39-40

A Commence iv oxytocin
B Deliver by caesarean section
C Fetal blood sampling
D No additional intervention at this stage
E Umbilical artery Doppler
F Reduce oxytocin dose
G Uterine artery Doppler
H Forceps delivery
I Intravenous ritodrine
J Administer maternal facial oxygen
K Sub-cutaneous terbutalline
L Administer uterotonic agent

Instructions: For each of the case histories described below, choose the single most appropriate initial management from the above list. Each option may be used once, more than once, or not at all.

Nick Raine-Fenning · Posted: Sun May 25, 2008 12:34 pm Post subject: Re: Syntocinon for VBAC

Nick Raine-Fenning · Posted: Sun May 25, 2008 12:36 pm Post subject:

Step 1: read the options

If we accept that the questions are most likely to relate to intrapartum management we can already delete several options including:

E Umbilical artery Doppler

G Uterine artery Doppler

J Administer maternal facial oxygen

The first two are not appropriate in labour and the last option is not evidence-based and may result in a worse outcome.

Nick Raine-Fenning · Posted: Sun May 25, 2008 12:38 pm Post subject:

Step 2: read the question

Nick Raine-Fenning · Posted: Sun May 25, 2008 12:41 pm Post subject:

Step 4: underline the key points

Nick Raine-Fenning · Posted: Sun May 25, 2008 12:43 pm Post subject:

Step 5: (imagine) present the case to someone

Secondary arrest at 7cm in a parous women with a previous CS who is now contacting poorly but who laboured spontaneously.

Nick Raine-Fenning · Posted: Sun May 25, 2008 12:44 pm Post subject:

Step 6: read the stems again and select the possible options

A Commence iv oxytocin
B Deliver by caesarean section
D No additional intervention at this stage
L Administer uterotonic agent

You then need to apply your knowledge - is oxytocin an appropriate option and can the woman be left without intervention?

So let me ask you ...

1. is oxytocin contraindicated for VBAC?

2. does the fact this woman has delivered since her CS matter?

3. does the fact she laboured spontaneously and then developed 2ry arrest affect the answer to the two questions above?

docsubhi · Joined: 03 Sep 2007 Posts: 51 Location: london

Thanks Nick

She is a multip who had her first section because of breech presentation. The most important indicator for a successful VBAC is a previous vaginal delivery (as per RCOG VBAC guideline)

If she is contracting 2-3 in 10 with a normal CTG she can have a trial of syntocinon ( I would have thought and what we practise in our unit(S) ), but the answer given is LSCS

Nick Raine-Fenning · Posted: Sun May 25, 2008 3:51 pm Post subject:

Two things:

1. 'your unit' does not exist Wink

You must use the RCOG and other International peer reviewed Guidelines (as should your unit by the way Razz

)

2. is oxytocin safe for a 2ry arrest in a spontaneously labouring woman who has demonstrated she can deliver vaginally after her CS?

My feeling is NO and I would agree with the answer therefore.

Where is the question from and what evidence do they give to support their answer?

This is a good quesiton and one that should allow us to discuss VBAC and then develop it into a nice SAQ.

Can I ask you to go to the key guidelines and update us all?

N

Xerxes I · Posted: Sun Jun 08, 2008 4:29 pm Post subject:

It's a tricky one.

I couldn't find anything specifically on secondary arrest and VBAC but the RCOG says the ideal contraction frequency for augmented VBAC is 3-4 (as opposed to 4-5 for normal asper NICE). We don't know how long she has been having irregular 2-3 contractions.

I know I am confusing myself and I agree that what they want to hear is probably that we know we shoudn't make this decision lightly and therefore the answer has to be CS but I don't find this one easy to answer.

Nick Raine-Fenning · Posted: Sun Jun 08, 2008 5:47 pm Post subject:

Agreed - always chose the safest option however. There is no harm (apart from the obvious) in doing a CS but there is great potential for harm if she is augmented / accelerated (and the choice of those two words is another debate altogether!).

Keep reading (you and others) to see if we can get some more info here. You have opened a very interesting and topical discussion.

Xerxes I · Posted: Sun Jun 08, 2008 6:41 pm Post subject:

This is about secondary arrest in general and I've stolen it from Leusley and Baker.

"in one series of patients with secondary arrest, 60 per cent of nulliparae and 70 per cent of multiparae demonstrated an improvement in progress with oxytocin.' However, the caesarean section rate was ten times greater in the treatment arm than in the uncomplicated cohort. "

"Friedman observed that delay during the decelerative phase on a partogram, between cervical dilatations of 7 and 10 cm, was associated with an increased risk of failure to respond to oxytocin augmentation and difficulty in procuring a successful instrumental vaginal delivery."

Nothing that new here, the theme is be careful before starting synt in secondary arrest. VBAC and secondary arrest I think we should say unless there is an obvious loss of contractions associated with failure to progress and in the absence of all that we know, synt is not a good idea.

Can I ask a silly question? You know we say you should check for malposition in secondary arrest. What do you do with your findings? I mean if its brow, complex etc, its obvious but if its deflexed OP and secondary arrest, well is it not a good reason to actually give synt a try? So am i right that checking for malposition is to check for undeliverable malpositions right? or am I talking absoloute nonsense?

Nick Raine-Fenning · Posted: Mon Jun 09, 2008 9:08 am Post subject:

No you are not talking nonsense - you have hit on a very important point that is rarely if ever discussed.

Not sure is the answer. My viewpoint is that a malposition (OP etc) may be the reason for poor progress and so you could accept that. Not sure if synto would work but there you go. If the position is normal then I would be more worried but it may also mean the uterine activity is poor hence synto is needed. Then again is the head OP because there is poor uterine activity?

These data come from South Africa and one could argue need repeating. There's a degree / project for you! Smile

Xerxes I · Posted: Mon Jun 09, 2008 5:27 pm Post subject:

In think once our O&G for dummies book is out and sold out, we could publish: "all you wanted to know about Obs and Gynae but were afraid to ask".

About the project you are suggesting, malposition and synt and progress and length of each stage and defining labour and when it started and epidural and VE validation and different practices etc. etc, I am not surprised it's not repeated ever again. I think the south African chap has jumped from a bridge or gone under a train or something after that paper. what have I done that you hate me this much? Wink

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 949

he doesn't hate you Xerxes!! Shocked

. i thought it's not a bad idea if one has the patience and right dose of crazy to offer Wink

.......
' when did labour start? ' --- that question is itself as bad as, what came first the Chicken or the Egg?

thank God my mind is not Obst but Fert orientated, i won't be tempted to do that one. Laughing

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

Nick Raine-Fenning · Posted: Tue Jun 10, 2008 5:34 pm Post subject:

yes but these 'back to basics' studies are often the easiest. Challenge conventionally held concepts and ask for the evidence. If it is not there do a RCT!