TEALE FENNING

EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

35 year lady, P3 ,she have previously 2 vaginal delivery but the last pregnancy terminated by emergency CS at 33 wks due to pre-eclampsia. Now she is 27 weeks gestation, her blood pressure is 140 / 90 mmHg, she is on methyldopa 250 mg tid , she is asking about the possibility to have vaginal delivery in this pregnancy.

A] How would you counsel her regarding VBAC? [10 Marks]
B] How much her risk to develop pre-eclampsia in this pregnancy.?[3 Marks]
C] What would be your plan for her current management ?[7 Marks]

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 927

EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

New evidence is emerging to indicate that VBAC may not be as safe as originally thought.
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Green Top Guidline 2007

If this woman who had 2-10% chance of developing pre-eclampsia; are you going to do IOL for her ?!

EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

Women with a prior history of one uncomplicated lower-segment transverse caesarean section, in an otherwise uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of planned VBAC and the alternative of a repeat caesarean section (ERCS).
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This woman had complicating pregnancy before;
I can add a question:
How would you advice her ??

EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

See this also:
Women who are preterm and considering the options for birth after a previous caesarean should be informed that planned preterm VBAC has similar success rates to planned term VBAC but with a lower risk of uterine rupture.

EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

so we can say:
In this lady, if her previuos CS was uncomplicated, and now she do well with no evidence of pre-eclampsia we can advice for induction of labour at term especially she had vaginal birth before,however, this carries the risk of rupture uterus about 22-74 / 10 000.

If she develop progressive worsenning of blood pressure or protinuria, we can induce labour ,preterm induction, which carry the same success rate of term induction with less risk of rupture uterus.

If patient deteriorate rapidly , so rapid termination is anticipated.

A final decision for mode of birth should be agreed between the woman and her obstetrician before the expected/planned delivery date (ideally by 36 weeks of gestation).
Smile

EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

Some figures from Patient UK:

@ Any pregnant woman can develop pre-eclampsia. It occurs in about 1 in 14 pregnancies. Some have an increase incidence like previous Hx, family history, changing partner, etc.

@ About 1 in 30 women develop pre-eclampsia in their first pregnancy or if they change partner.

@ About 1 in 5 pregnant women with high blood pressure progress to pre-eclampsia.

@ If the woman had pre-eclampsia in her first pregnancy, she has about a 1 in 10 chance of it recurring in future pregnancies, however, it is unusual to develop it in future if you become pregnant again by the same partner.

EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

Risk factors for unsuccessful VBAC:

1- Induced labour
2- No previs VB
3- BMI > 30
4- Previos CS for dystocia, previos baby wt of 4 000 Kg or more.
5- Previos preterm CS
6- VBAC at 41 wks or more
7- Cervical Dialatation of less than 4 cm on admission
8- Less than 2 years from the previos CS
9- Advanced maternal age
10- Short stature
11- Male infant
12- Non white ethnicity

The success rate can fall from 72-76% to 40 % Sad

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EMAK · Century Club Joined: 26 Nov 2006 Posts: 578

Contraindications for VBAC:

1- Previous one classical CS
2- Any uterine scar apart from uncomplicated LSCS
3- Any contraindication for vaginal birth
4- Previous Complicated LSCS