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MRCOG PART II ESSAY 275 - VBAC

Posted by Mahnaz A.

A healthy 34 year old woman attends the antenatal clinic at 21 weeks gestation following a normal anomaly scan. She has two previous caesarean sections and wishes to have planned vaginal birth. (a) Discuss your assessment and counseling [15 marks]. (b) She presents at 39 weeks gestation with spontaneous rupture of the membranes but no uterine contractions. Discuss your antenatal management [5 marks].

a.The assessment starts with the review of her previous caesarean delivery. Ideally it should be by reviewing her obstetric records and to identify the indication, the uterine incision and any perioperative complications such as uterine incision extension, endometritis and wound infection which increases risk of uterine scar rupture and pelvic adhesion. Factors such as CPD or failure to progress in late first or second stage of labour may recur and reduce likelihood of VBAC. Detail of her current pregnancy should also be reviewed. Interval between the pregnancies should be enquired.Placental localization should be checked and if it is found low lying at 21 weeks, then rescan should be done at 32-34 weeks. Diagnosing placenta praevia or accrete at 32-34 weeks should preclude VBAC and consideration given for planned CS after discussion between woman and the consultant.

The woman should be properly counseled with all available information. She should be informed that studies have shown no major differences between the rates of VBAC success, uterine rupture and hysterectomy between one and two previous caesarean sections. The success rate of VBAC is 72-76% and it increases if she had previous history of vaginal birth which is about 87-90%. The success rate is reduced in induced labour, prolonged pregnancy, baby weight >4000 gms, shorter interval between deliveries. The woman should be informed about the risks and benefits of VBAC. The risks include uterine rupture (22-74/10000), 1% additional risk of endometritis and blood transfusion, increased birth related perinatal mortality and still births after 39 weeks of gestation. There is also increased risk of hypoxic ischaemic encephalopathy compared to ERCS. But there is no increased risk of hysterectomy, VTE or maternal death compared to ERCS. VBAC has the benefit of reduced neonatal respiratory problem while planned cs has increased risk of maternal morbidity. The contraindications should also be discussed such as previous uterine rupture and high vertical incision. In the event of prolonged pregnancy, the success rate of VBAC is reduced and induction of labour with prostaglandin carries more risk of uterine rupture.

The counseling should include importance of compliance with antenatal follow up in consultant led unit. All the discussion and counseling should be documented and the plan of delivery is decided by 36 weeks. A plan for the event of labour prior to the scheduled date should also be documented. Detail of intrapartum monitoring should be informed. Information leaflets should be provided to her.

 

b. The premature rupture of membranes as suggested by her history should be confirmed by sterile speculum examination and in equivocal cases, nitrazin or fern test can be done though both have high false positive and high false negative rates. Vaginal examination is done to assess the Bishop score. Full blood count, CRP and vaginal swab are sent and the woman should be admitted for observation for signs of clinical chorioamnionitis- maternal pyrexia, tachycardia, uterine tenderness, foul smelling vaginal discharge. CTG can be done to detect fetal tachycardia which is indicative of intrauterine infection. Erythromycin should be started which reduces maternal and neonatal morbidity.

Consultant led counseling should be done with the woman regarding the timing and mode of delivery. Expectant management can be considered if there is no evidence of fetal or maternal compromise. Almost 90% enters into spontaneous labour by 24-48 hours. On the other hand, induction of labour should be discussed and informed her thatinduction with prostaglandin carries increased risk of uterine rupture.

The decision regarding delivery should be decided by consultant obstetrician upon discussion with the woman.

 

 

 

VBAC Posted by D M.

I would like to review this patient’s previous obstetric notes together with discussing with the patient as to the reasons of the previous 2 c/s as this influences the outome of VBAC in this pregnancy. From the obstetric history we would review if there are any contraindications to VBAC such as classical uterine incision(increases risk of uterine rupture by 9%).T or J uterine  or low vertical are relative contraindications that we need to take into account before counselling  VBAC as there is an increased risk of uterine rupture  of 2% .I would also advice the patient that although there is no significant difference in the rate of uterine rupture in VBAC with 2 or more c/s compared to a single previous c/s, the rate of hysterectomy and blood transfusion are higher.

I would also discuss the risks associated with VBAC which are uterine rupture of 1 in 300.There is an additional increased risk of 1% of endometritis and 1% additional risk of blood transfusion compared with elective c/s. There is a very small but significant risk of 8 in 10000 for the newborn to suffer hypoxic ischaemic encephalopathy with unkown long term effects to the baby. There is even smaller but significant risk of 2-3 in 10 000 for birth related perinatal death compared to elective c/s. The chance of achieving a vaginal birth after a single c/s is 75% but depending on any additional risk factors this percentage can be lower. These risk factors are obesity(BMI higher than 30,less than 2 years from previous c/s,need for inducing or augmenting labour,estimated fetal weight more than 4 kg, not having an epidural in labour,being admitted to labour ward with less than 4 cm dilated cervix, short stature and advanced maternal age which in her case is not an issue). Having had a vaginal delivery before the chance of achieving a vaginal delivery is approximately 85%.

An emergency c/s  in labour after failing of VBAC is associated with higher maternal morbidity than an elective c/s.There is not an increased risk of venous thromboembolism,hysterectomy or maternal death compared to an elective c/s. There has also been reported an increased risk of antepartum stillbirth beyond 39 weeks having had a previous c/s. 

I would then discuss the benefits of a VBAC. There is a reduced risk of neonatal respiratory problem in successful Vbac as compared to an elective c/s. I would discuss future plans of further family as repeated c/s increases the risk of placenta praevia/placenta accrete,injury during the c/s in different organs such as bladder,bowel,ureter.It also increases the risk of hysterectomy,admission to highdependency unit,blood transfusion and hospital stay.

I would also give VBAC leaflets to take home and clearly document our discussion in the current antenatal notes.  If a clear management plan is not decided at this point in time, a clear decision depending the patient’s risks and most importantly her wishes needs to be clearly documented by 36 weeks gestation. The plan should include whether the patient wishes to be augmented,induced or expectantly managed as well as instructions during labour(EFM,analgesia,place of birth)

(b) I would review this patient’s notes as to what plan has been decided antenatally.

I would monitor the baby with CTG ensuring there is no fetal compromise. I would clinically examine patient,her vital signs excluding chorioamnionitis by checking maternal temperature,tachycardia .I would also palpate abdomen for any uterine tenderness,contrations and presentation,if in doubt i would perform bedside US scan to exclude breech presentation.I would do a speculum examination to check colour of liquor(meconium or blood stained) and cervical dilation and defer my vaginal examination until after counselling the patient as to further plan.

I would discuss the options of either augment labour as soon as possible with oxytocin, augment labour in 24 hours, having a c/s without trial of vaginal delivery and expectant management. I would explain that 60 % of patients with prelabour rupture of membranes go into spontaneous labour. The risk of not augmenting straight away would be the risk of infection to herself and the baby. Having to augment with oxytocin in someone with previous c/s increases her risk of uterine rupture above the background risk by 0.4%.

In labour I would suggest patient to be admitted on consultant led unit with continuous EFM .The labour ward should be well equipped if immediate need for emergency c/s and neonatal rescusitation. I would advice epidural analgesia for pain relief, organise a group and save and ensure senior obstetric and midwife staff on labour ward for her care. Be cautious for any signs of uterine rupture such as abdominal pain,vaginal bleeding,non reassuring FHR,ascending fetal station,maternal hypotension,tachycardia,collapse,shoulder tip pain.

 

essay 375 vbac Posted by MONA V.

 

a )The reason for her request is explored. Previous obstetric history noted regarding indication for previous caesareans as induction of labour and failure to progress make success of planned vaginal birth less likely. The type of incision on uterus noted as previous classical incision would mean vaginal birth is contraindicated due to high risk of rupture uterus. Any previous vaginal delivery would increase chance of vaginal delivery. Future reproductive intentions are asked . BMI is noted. Placenta previa or accreta in scan would require follow up scans to decide mode of delivery.

She is counselled that both choices of planned vaginal birth and elective planned caesarean are safe with own risks and benefits. She is more likely to have caesarean delivery due to previous two caesarean but if she goes in labour chance of successful vaginal delivery is 70-75%. She should be seen under consultant led care with written plan for labour by 36 weeks. She is counselled about   advantage of planned vaginal birth as it avoids surgery, shorter recovery period,  shorter hospital stay  and less abdominal pain after birth. There is greater chance of vaginal birth in future pregnancies. The disadvantage of vaginal birth would be one in 4 would need emergency caesarean operation which could have more morbidity than planned caesarean. There is risk of scar rupture in 2 to 8 per 1000 women undergoing vaginal delivery which will need emergency caesarean. There is more chance of blood transfusion , haemorrhage and infection of uterus with vaginal delivery. There is additional small risk of neonatal death and brain damage in babies delivered by vaginal delivery as compared to by planned caesarean delivery. Her chances of successful vaginal delivery are less if she does not get into labour spontaneously , BMI more than 30,  never had previous vaginal delivery.

She is also told of advantage of planned caesarean like virtually no risk of scar rupture, date known in advance so less anxiety about outcome and avoiding the risk of labour to mother and baby. The disadvantage like more difficult surgery, risk of venous thrombosis and longer hospital stay is also told to help her make informed decision.

Plan for labour should take into account maternal wishes and reviewed at 36 weeks in case of any change of decision with discussion with consultant. Any antenatal complications at term like preeclampsia means that vaginal birth is not offered. Document plan for labour if it starts early. Document plan if she dos not get into labour . Induction of labour, time and place of induction discussed. Associated risks like two fold increase in scar rupture need for continous fetal monitoring documented. She is given written information.  Leaflet.

b)  In case of prelabour rupture of membranes (PROM) ask for duration of membrane rupture. She is asked for any bleeding  fetal movements. She is asked for excess vaginal discharge , urinary incontinence which can be confused with liquor. Examine   pulse , temperature for chorioamnionitis . Abdominal examination for any contractions , uterine tenderness , presentation , estimated fetal  weight fifths palpable, fetal  heart by CTG.  Speculum examination for pooling for liquor to confirm PROM .   Vaginal  examination done to  assess bishop score.  Any  meconium liquor, bleeding   fetal  heart abnormalities , malpresentation deliver by emergency caesarean. Options of induction with prostaglandin , oxytocin augmentation  and expectant management are discussed. 60% of women with PROM go into labour spontaneously. Epidural for analgesia is recommended , group and save done. 

essay 375 VBAC Posted by sowba B.

 

The reasons for the womans request and her attitude towards the rare but serious risks involved in VBAC after two caesareans has to be considered. Success rate for VBAC is 72 -76% in an uncomplicated term pregnancy and a consultant should make the decision.Her old case notes must be reviewed to note the previous two caesareans’indications as if it was done for dystocia ,the chance of successful VBAC is less,so also is the case with the last caesarean done within the last two years.The type of uterine incision is to be noted as the risk of uterine rupture is more with a classical 200-900/10000 ,inverted T or J 190/10000  ,a low vertical 200/10000 compared to a low transverse 22-74/10000 .Any perioperative complications are also noted. Whether the second time a VBAC was attempted and was unsuccessful is important as it favours an elective repeat caesarean now to avoid complications.During the course of this pregnancy, she should not develop any comorbidities like preeclampsia,gestational diabetes.her BMI should not cross 30 as it reduces the chances of a successful VBAC .Other factors leading to less success rates are a previous preterm caesarean,maternal short stature,macrosomia >4000g, induced labour,nonwhite ethnicity ,no epidural analgesia in labour.If  there is a history of scar rupture previously ,or previous incision not low transverse or placenta previa/accreta in current pregnancy then VBAC is absolutely contraindicated.T he womans  height has to be checked and BMI calculated .any pallor has to be noted and fundal height and fetal heart checked. A thorough counselling has to be done and documented.the benefits of VBAC are avoiding caesarean related problems like fever,wound infection and in her case with two previous caesareans,injury to bladder, bowel,haemorrhage,hysterectomy, prolonged immobilisation, ileus, VTE, admission to ICU and post op ventilation are te risks.Risks of VBAC are uterine rupture 22-74/10000, additional 1% risk of endometritis and blood transfusion,additional 2-3/10000 birth related perinatal deaths ,increased still births after 39 weeks with an overall increase in perinatal mortality,an 8/10000 risk of hypoxic ishchemic encephalopathy to baby,long term outcome not known. Uterine rupture in previous two scars comparable to single scar being 92 and 68/10000,but hysterectomy and transfusion are more 60 and 20/10000 ,and 3.2% versus 1.6% respectively .She should be given Information leaflets, support group details  like www.moormums.co.uk and allowed to make an informed choice.

                               In labour the womans willingness for VBAC has to be reconfirmed,consent taken and decision should be consultant led.Cervical bishops score,estimated fetal weight,colour of liquor has to be seen .An admission CTG is essential.If liquor is meconium stained an emergency caesarean is to be done. If liquor clear ,  admission trace reactive, as there are no contractions augmentation with oxytocin can be started,again a consultant led decision.rate adjusted such  that there are not >4contractions in 10 minutes. She should be on continuous CTG monitoring as CTG abnormality is the first sign of impending rupture.A 1to1 care by a senior midwife is necessary.signs of impending rupture are sudden pain in absence of contractions,shoulder tip pain,shortness of breath,scar tenderness,maternal tachycardia,hypotension,cessation of contractions loss of station of presenting part.  Careful vaginal exam preferably by same person to note cervicometric progress is required .The woman and her partner are to be kept informed of the high probability of caesarean section.  An early decision for caesarean If non progress is decided by consultant.Facility for emergency caesarean and advanced neonatal resuscitation is mandatory.Induction with Prostaglandins if cervix unfavourable is not contraindicated but gel may get washed out with liquor,also risk of rupture and caesarean increases 2-3fold and 1.5 fold. 

 

Essay VBAC Posted by Dr Sanhita  K.

 

A. The assessment would include review of the previous surgical notes regarding the indication for the caesarean sections , the uterine incisions and any associated complications.  History of the gestational age during caesarean sections and the interval from the last childbirth needs to be enquired into. Classical caesarean section is associated with a risk of scar rupture of 200-900 in 10,000 deliveries and is a contraindication for Vaginal birth after caesarean. A history of scar rupture too is a contraindication. J shaped and Inverted T incisions are associated with higher rupture rates. Caesarean section for dystocia and preterm caesarean are associated with lower success rates of vaginal birth . A shorter inter pregnancy interval of less than two years is also associated with increased failure rates..

Any complication in the present pregnancy should be taken into account. Multiple pregnancy , Placenta praevia are contraindications to vaginal birth.. Obesity is also associated with higher failure rates. The location of placenta, if Low lying or anterior during the anomaly scan needs to be reconfirmed at 32 weeks. Placenta  praevia  accreta is a contraindication for vaginal birth after caesarean , is associated  with major obstetric haemorrhage  and needs repeat  caesarean section with additional preparations.

 

The woman should be counselled that  if she has  2 previous uncomplicated caesarean sections, she may be allowed a vaginal birth trial after detailed risk assessment by the consultant obstetrician and informed consent .  Delivery would be in a consultant led unit with facilities for emergency caesarean sections, blood transfusion and neonatal intensive care unit.. Any other previous uterine scar or history of rupture mandates a planned repeat caesarean section at 39 weeks.

She should also be informed that the rate of uterine rupture is not significantly increased compared to one previous section but there is higher risk of blood transfusion and hysterectomy compared to  a single transverse section. The success rate of VBAC is 72-76%.  The risk of uterine rupture is 2-8 in 1000 births. There is also an additional 1% risk of endometritis and blood transfusion  compared to ERCS.  There is also an increase in the risk of birth related perinatal deaths by an additional 2-3/10,000 births compared to elective section .The risk of antepartum stillbirths beyond 37 weeks is increased in the VBAC patients and so is the risk of Hypoxic ischaemic encephalopathy  of 8/10,000.

Vaginal birth is associated with a decreased risk of transient tachypnoea of the newborn by 2 % compared with repeat caesarean section delivery. Failed VBAC is associated with a poorer outcome of  uterine scar dehiscence or rupture, blood transfusion, hysterectomy and birth asphyxia of the neonate.

 

The patient should also be informed that repeat caesarean section has no risk of scar rupture and is associated with lesser in cadence of perineal pain and trauma. There is howevever longer hospital stay and longer period of delivery. There is also increased risk of injury to the bladder bowel, ureter . The risks of placenta praevia and accrete increase with each additional caesarean section. The patient should be provided information leaflets regarding risks and benefits and the discussion should be documented in the hand held notes.

 

B.  The woman should be asked about the duration of rupture of membranes, associated pain abdomen, bleeding and about fetal movements. The pulse rate , temperature, BP should be checked and per abdominal examination done to assess presentation, uterine size, uterine contractions ,and auscultate the FHR. An admission CTG  would be done as she is a high risk patient. Per speculum examination to document ruptured membranes, colour of liquor and digital examination to assess cervical dilatation, effacement, position is done. Prior to vaginal examination placental localization should be confirmed by review of the antenatal notes.. Expectant management for 24 hours is associated with spontaneous onset of labour in 60% cases.. Induction of labour in this patient with previous two sections is associated with 2-3 fold higher  risk of uterine rupture and needs counselling and evaluation by the consultant. Unfavourable features for vaginal delivery would necessitate  a caesarean section.

A healthy 34 year old woman attends the antenatal clinic at 21 weeks gestation following a normal an Posted by Jandy F.

My assessment with include inquiring with the woman regarding her previous caesarean section and also going through her Obstetric notes. This will enable to find any absolute contraindication and assess the success rate and help me to counsel her regarding the mode of delivery.

I will identify the indication for previous caesarian section, previous birth weight of babies., consider the uterine incision any associated post operative complications namely – endometritis, blood transfusion

I will also inquire regarding  patient had any previous uterine operation involving opening the cavity like myomectomy .

If the uterine incision are classical incision, extended incision like inverted T or J incision then it is an absolute contraindication  for VBAC as increased chances of rupture of uterus of 2-9% and 1.9% respectively, as per RCOG guidelines.

 

If there are no complications and the current pregnancy is uncomplicated can offer the VBAC and the success rate is for one previous c/s is @ 72-76%  and 2 previous section is 62-75% which is a not very significantly different.

 

I will also consider the other factors to give a success rate such as :

previous section – preterm c/s,   c/s for cervical dystocia, previous failed VBAC, less than 2yrs interval between pregnancies decrease the success rate @ 40%

Other factors to be included are the maternal age , short stature , expected birth weight if more than 4kg and if has to induce labour and prolonged labour will further decrease her success rate.

 

I will  explain the associated risk and benefits of VBAC  v/s ERCS .

The risks  are uterine rupture (92/10000), hysterectomy-0.6% ,Blood transfusion 3.2% which are slightly higher than one previous section.

Additional 1% risk of thromboembolic  disease and endometritis over elective caesarian sections.

There is no risk of rupture of uterus in elective c/s however increased risk of placenta previa, injury to bowel and bladder and ureters, paralytic ileis, need of post op ventilation , hysterectomy, blood transfusion and increased hospital stay and recovery time. Also there is and element of respiratory distress syndrome in babies(3-4%)

 

Regarding the fetus-perinatal deaths 2-3/10000   and hypoxemic ischemic encephalopathy- 7.8/10000 of which 50% related to rupture of uterus during the labour. RDS in babies are 2-3%.

 

In this pregnancy if the subsequent scan rule out adherent placenta, and if cephalic presentation, plan is usual to allow the patient to go in spontaneous labour .Offer sweep at 41wks and also CTG on Day care unit. Induction if required ,will be in form of Balloon Catheter  and no using the prostaglandins as increased rate of rupture by 2-3 fold and 1.5fold increase in emg c/s.

If in spontaneous labour will assess the dilation and prefer ammniotomy and augment labour and Intensive intrapartum monitoring for signs of rupture of uterus will be undertakenand also limit the hours in labour. Can offer epidural in labour .

 

Document the counseling offered  and plan of event of labour prior to scheduled date should be documented and leaflets to be given and review her ANC consultant led clinic at 36wks for further discussion regarding the mode of delivery.

 

 The lady presented at 39wks with pre labor rupture of membranes , I will ask the time when she ruptured membranes and any pv bleeding.

Ask about fetal movements and the contractions. Inquire with her regarding the plan of mode of  delivery

Assess pulse , BP and monitor the fetus by CTG .. I will do an abdominal examination, assess the presentation, contraction and asses whether head is fixed or engaged, also check for scar tenderness. Offer the  sterile speculum examination to confirm the rupture of membranes and conduct internal examination assess the dilatation if more than 4 cm  and head is entered the pelvis than the chances of sponteous delivery are increased .

Discuss with patients options VBAC and CS , if she is keen to proceed with VBAC , depending with hospital policy and consulting the Consultant will offer her augmentation with Oxytocin or wait for 24 hrs with intermittent monitoring on the ward.I would explain that 60 % of patients with prelabour rupture of membranes go into spontaneous labour. There is  risk of infection to herself  and baby. Having to augment with oxytocin in someone with previous c/s increases her risk of uterine rupture above the background risk by 2-3 fold, and 1.5% of emergency c/s.

we will monitor intrapartum period , and be vigilant for signs of rupture of uterus and fetal compromise. Can offer epidural  for analgesia.

We will obtain iv access and assess 4hrly for progress after 3cm of dilatation and every 2hrly after 7cms, if no adequate progress i.e and if no progress over 6-8 hrs unlikely to delivery  -proceed for emg c/s or no change in cervicometry over 2hrs than labour dystocia and emg c/s

If fully dilated –allow 1 hr of descent and 1hr of pushing  no progress trial of forceps or ventouse in theatre under supervision of Consultant.

Do not have to assess the uterine scar following third stage unless persistant pv bleeding discuss with the consultant for further advise .

VBAC Posted by Sailaja C.

 

The aim of the assessment is to determine the likelihood of successful VBAC and to identify any contraindications to VBAC. Prior history of two uncomplicated low transverse caesarean section in an otherwise uncomplicated pregnancy at term is no contraindication for vaginal birth who have been fully informed by consultant obstetrician.

 

History is taken about the details of her parity. Previous vaginal birth , particularly previous VBAC  is predictive of successful vaginal birth where as no vaginal birth is associated with unsuccessful VBAC. Time since previous caesarean section is noted as interval of less than 2 years is associated with decreased likelihood of successful VBAC. 

It is important to access previous maternal records to know the details of previous caesarean sections. 

Classical caesarean section is an absolute contraindication for planning vaginal birth. Type of the uterine scar other than low transverse uterine incision like low vertical, or J shaped incision are associated with risk of uterine rupture. 

 

Gestational age at previous caesarean section is important as previous preterm caesarean birth is associated with decreased successful vaginal birth as caesarean section at a preterm gestation necessitates vertical incision for the delivery of the baby which has increased risk of uterine rupture during labour. 

Her ethnic status is noted as non white ethnic status is associated with reduced success of VBAC.

 

Her BMI assessed. BMI of more than 30 and short stature are associated with  lesser likelihood of successful VBAC.

 

Ultrasound scanning is done to identify the location of the placenta . If the placenta is covering the os, follow up scan is required at 32 weeks and major degrees of placenta previa is a contra indication for vaginal birth. 

She should be informed about the benefits of VBAC probably reduces the risk of neonatal respiratory problems: 2-3% with planned VBAC and 3 - 4% with planned C/S.

She should be informed that prior history of two uncomplicated low transverse caesarean sections in an otherwise uncomplicated pregnancy at term with no contraindication for vaginal birth may be considered for planned vaginal birth after being fully informed by a consultant obstetrician.  The success rates of VBAC after two caesarean sections is similar to those with single prior caesarean birth

But information is given that planned VBAC carries a risk of uterine rupture of 22-74/10/000 . She should be explained that according to studies, there was no significant differencee in the rates of uterine rupture in VBAC with two previous caesarean birth compared to single previous caesarean birth. However rates of hysterectomy and blood transfusion are increased in women with prior 2 caesarean sections. 

She should be informed that the risk of blood transfusion increases by about 1% and  the chance of endometritis increases by about 1%. VBAC is associated with 2-3/10000 additional risk of birth related perinatal mortality . She is given information that planned VBAC carries an 8/10,000 risk of the infant developing hypoxic ischaemic encephalopathy which may have long-term developmental implications.

 

B) 

Consultant obstetrician is involved regarding the antenatal management. 

History is taken regarding time since rupture of the membranes, colour of the liquor, meconioum or blood stained.  She should be asked if she had noticed any foul-smelling vaginal discharge, fever and rigours. Maternal records are reviewed to look for any contraindication for vaginal birth . The plan of  management regarding mode of delivery is reviewed which is agreed by the patient and her obstetrician at around 36 weeks of gestation. 

 

Enquiry is made regarding vaginal bleeding and if she is feeling fetal movements.

 

Temparature, pulse and blood pressure are recorded.

 

Abdominal examination is performed to assess the uterine height, lie and presentation of the foetus . Uterine tenderness is excluded which suggests uterine infection. 

CTG is performed to assess fetal well being.

Sterile speculum examined to done to confirm the leaking and for assessment of the cervix.

Swabs are obtained to screen for genital infection. 

FBC and CRP are done as baseline investigations.

Maternal wishes are considered regarding the mode of delivery if she had changed her wishes about having vaginal birth.  

Abnormal presentation like breech and brow are indications for caesarean section. 

If vaginal birth is planned, expectant management is an option in the absence of infection and fetal compromise which prompt immediate delivery by caesarean section.  Oral erythromycin is given to prevent infection. 

 

Monitioring is done by enquiry of pain abdomen, foul smelling discharge.  Raising WBC count and CRP suggest chorioamniotis . Daily CTG done to  monitor fetal well being. 

Usually around 60% of women progress to  spontaneous labour within 24 hours. If she doesn't progress to spontaneous labour within 24 hours, decision regarding mode of delivery should be reviewed as there is risk of chorioamniotis. 

  

Induction of labour , especially by prostaglandins is associated with risk of uterine rupture and the decision should be taken by discussing with the consultant after taking maternal wishes in to consideration. 

Posted by amina  .

A healthy 34 year old woman attends the antenatal clinic at 21 weeks gestation following a normal anomaly scan. She has two previous caesarean sections and wishes to have planned vaginal birth. (a) Discuss your assessment and counseling [15 marks]. (b) She presents at 39 weeks gestation with spontaneous rupture of the membranes but no uterine contractions. Discuss your antenatal management [5 marks].

 

I will take detailed history about previous caesarian sections and indications for caesarian section .it will help in  decision and couselling the woman about the risks and benefit s of planned vaginal birth.classical caesarian section is contraindication for planned vaginal birth. i will reveiw the notes of previous surgeries if available to know the type of uterine incision , any extension of uterine scar , adhesions.previous notes reveiw will give information about complications during surgery like injury of bowel/bladder.

 i will ask about her parity and any vaginal birth before , as it increases likehood of successful planned vaginal birth.i will ask about her furture fertility plans .i will inquire the reasons why she wishes for vaginal birth . i will ask about previous surgeries like myomectomy / hysterotomy as it increases the risk of uterine rupture .i will check previous babies  birth weight and ask about history of diabetes , as macrosomia increases the risk of uterine rupture.

short interdelivery interval also carries risk of uterine rupture , so i will inquire about interdelivery interval.

BP and BMI  should be checked . i will look for signs of anemia  , as correction of anemia with oral  ferrous sulphate  will reduce need for blood transfusion.

decision about planned vaginal birth after 2 caesarian sections should be made between consultant and woman after consultant led counselling. i will inform her that the is risk of uterine rupture in VBAC is about  22-74/10,000.  it  increases in  her case  as she have 2 caesarian sections.

VBAC  carries 1% additional risk of either blood transfusion or endometritis. it is associated with   2-3/10,000 additional risk of birth related  perinatal mortality. it carries risk of hypoxic ischemic encephalopathy about 8/10,000 .

it has reduced risk that her baby will have respiratory problems after birth. elective repeated caesarian section carries risk of 3-4% as compared to VBAC with 2-3% risk.

i will inform about extremely low risk of anesthetist complications in both VBAC and elective repeat caesarian section.

i will inform her about the risks associated with caesarian section like injury to bowel/bladder , blood transfusion , hysterectomy.

i will inform her about implications of caesarian section in future pregnancies as it increases risk of placenta accreta.

i will inform her she may need augmentation / induction of labour in case of vaginal birth , these are associated with risk of uterine rupture .

risk of hysterectomy in planned vaginal birth after 2 caesarians is about 60/10,000. risk of blood tranfusion in planned vaginal birth  increases from 1.6% in previous 1 caesarian section  to 3.2% in previous 2 c sections.

i will document counselling in her notes. i will arrange her appointment with consultant . i will tell her that plan of delivery will be decided at 36wks . i will provide written information about VBAC and caesarian section.

 

 B   : MDT with consultant obstetrician , neonatologist , anesthetist , midwife with immediate ceasarian section facilities should be available.

 i will check her notes for decided mode of delivery and  plans for augmentation / induction of labour . i will inform consultant. i will asess fetal wellbeing by CTG . i will asess woman 's condition by BP , PULSE , TEMP . I Will check for uterine tenderness and colour of liqour. 

labour can be induced with prostagladins after consultant decision. it carries increased risk of uterine rupture. continous electronic fetal monitoring is indicated as abnormal CTG  is consistant finding in rupture uterus. epidural is not contraindicated but may mask signs of uterine rupture.one to one care should be provided. serial cervical assessments preferably by same person should be done.  

expectant management can be option but carries risk of chorioamnionitis .

if uterine contractions start , labour can be augmented with oxytocin to get 3-4 contractons/10mins.it carries risk of uterine rupture but comparatively less than prostagladins. 

if decision of delivery was caesarian section , emergency c. section will be performed .

 

ESSAY VBAC 275 Posted by Dr.Tamizharasi M.

) The reasons for her wish for VBAC after 2 previous LSCS has to be explored. Woman must be informed that chances successful vaginal birth in uncomplicated pregnancy  after previous 2 LSCS  is 64-74%. Detailed past obstetric history including whether it was spontaneous labour or induced labour because induced labour has decreased chances of successful   VBAC with increased risk of scar rupture. Review her notes to look for  Indications   for  both LSCS , because LSCS done for  dystocia decreases success of vaginal birth to 40%.Type incision for LSCS is looked for because classical incision  is one of contraindication for vaginal birth after caeserian section. Any history of vaginal birth is asked for, which increases the chance of successful VBAC to 85-90%.

     Increased BMI   more than 30kg/m2 may decrease the chance of VBAC. Woman is counselled regarding the risk involved in  vaginal birth including the need for emergency LSCS, the risk  of scar rupture is  0.5%, the need for blood transfusion(1%)  and the risk of endometritis has to be explained. Her wish for for future fertility is found out because successful VBAC increases  chance of vaginal delivery  in future pregnancies and ERCS increases serious risks in future pregnancies. Benefits of  vaginal delivery is explained like no risk of surgery, short hospital stay and recovery. Slightly  increased risk of loss of a baby (2-4/1000), and  brain damage due to reduced oxygen for the baby(8/10000) has to be explained .

     Her antenatal care is done in  hospital , consultant led care. USG report is reviewed to locate the placenta, if it is placenta praevia morbidly adherent placenta is looked for by USG with Doppler flow ,and conformation is done with MRI  to look for invasion.placeta praevia is one of contraindication for VBAC.Medical complications like preeclampsia , GDM has to be looked for  during antenatal checkup, in these cases  vaginal delivery is not offered. If she delivers  vaginally  risk for the baby due do breathing difficulty  is less(2-3%) compared to caesarean delivery(4%).woman must be counselled that she has increased chance successful vaginal birth if she come in spontaneous labour compared to induced labour. Detailed plane of care has to discussed with woman including the wish for epidural analgesia has to be documented in case record. Plan of care  if she comes in labour before that has to be recorded. If she does not go in to spontaneous labour  till 41 week either induction of labour or ERCS  is offered taking woman’s wish in to consideration. Written information leaflet is provided with follow up appointment.

              b) PROM  is confirmed with history of watery  loss and to look for pool of amniotic fluid in posterior vaginal fornix with speculum examination if history is not certain. High vaginal swab and  c- reactive protein is not  done if there is no risk of infection. Digital vaginal examination is not done if woman does not have uterine contraction on clinical examination.color of the leak and blood loss is noted . woman is given pad  to observe amount of watery loss. CTG is taken to assess fetal wellbeing and USG to look for maximum amniotic pool depth. Woman is advised  to go home if she is not in labour and CTG is reassuring . She is advised to take temperature every 4th hourly   , observe her fetal movements and for  any abdominal pain. Provide labour room contact number details  and report immediately if she gets labour pains or any  alteration in fetal movement .Woman is advised  review  after 24 hours for induction of labour/ ERCS if she does not go in to spontaneous labour in 24 hours(60%) as per her care plan  and taking woman’s wish as first consideration 

VBAC Posted by Reena G.

a)      In the  assessment of the patient I  need to review her  previous caesarean notes, indication of caesarean,whether non repeated cause like fetal distress or repeated  cause like  CPD or cervical dystocia, type of uterine scar uncomplicated  lower segment caesarean or complicated  like inverted t, j shaped or  classical where ERCS is recommended , any perioperative  complications like  blood transfusion , infection , fever  which might indicate poor initigrity of scar  which has limited evidence, her advance age and no  previous  vaginal birth  are  risk factor for less  successful VBAC. On examination her B.P. and BMI should be checked  as obesity is another risk factor for poor success. Her ultrasound should be checked about the placental position if covering os then to follow scan at 32 weeks  to know possibility of  praevia and accreta and recommended treatment then  is ERCS.

She should be counseled about risks benefit of VBAC and ERCS so as to enable her to take informed decision . Chance of successful VBAC  after 2 previous is 62-75 % and   Studies says that there is no significant difference in  risk of uterine rupture following one or two or more cesarean  sections  ,however the risks of hysterectomy and  blood transfusion is increased.with planned VBAC. The risks of rupture is more after induction and augmentation  of labour,  the neonatal respiratory morbidity is less than ERCS( 2-3% as compare to3-4%), there is 2-3/10000 additional  risks of delivery related perinatal morbidity with planned VBAC  as compare to ERCS,however it is comparable with first delivery birth. With planned VBAC the hypoxic ischemic  encephalopathy of infant  is more than planned ERCS(8/10000) , there is additional 1% risk of endometritis and blood transfusion  with planned VBAc but  there is low risks of anesthetic complications . In ERCS there is virtually no risk of rupture uterus, delivery can be timed but not always but has future risk to her regarding increase risk of placenta praevia ,accreta, hystrectomy  and blood transfusion.

She should be seen in consultant led  unit should be comprehensively  assessed by consultant.   Her mode of delivery to be discussed at 36 weeks and plan of labour if  she goes in early labour before due time or when and how to induce, progress of labour, parameters to intervene for cesarean section   . She should be delivered in tertiary care hospital with well  equipped staff and on site blood facilities with advanced neonatal care for resuscitation of baby.

The detailed counseling should be documented and information leaflets to be provided to her.

b)      She should be asked about onset and  duration of  rupture membranes ,any fever, vaginal discharge ( GBS status ) ,abdominal pain, fetal movements ,review her  notes  of  plan of management,  collect blood for  cross match in view of possibility of emergency caesarean  . Her vitals to be checked  and per abdominal examination done to check fundal height , presentation whether cephalic or noncephalic, fetal heart to be auscultated ,  any abdominal tenderness to be noted to look for signs of chorioamnionitis, any scar tenderness noted that will tell about integrity of scar.P/s checked for liquor, colour, any foul smelling discharge, p/v for dilatation and effacement of cervix and s tation of presenting part .

She should be counseled that majority of woman will have pains within 24 hours of rupture membranes  if not then  the consultant to be involved regarding the type of induction(pGE2 or oxytocin) , dose of induction, at what parameters to intervene further .

She should be given  one to one care once labour pains starts  and should be put for continuous electronic  fetal  heart monitoring, labour should be closely monitored for progress and should be aware of signs of rupture uterus (tachycardia, hypotension , presenting part high up , hematuria, palpable fetal parts, shoulder tip pain), there is no evidence to measure uterine pressure by intrauterine catheter to avoid uterine rupture.

 Cervical progress to be assessed by preferably  same person and any delay to be acted upon by doing emergency  caesraen section.Paediatrician  to be involved  at the time of birth in view of advanced resuscitation.

VBAC Posted by khalid M.

A] Take history about the two previous cesarean sections, their indications and duration from the last cesarean  .Revive her previous operative notes .  explain the women that the success rate of vbac after two previous cesarean section is about 62-75% .  vbac is successful if uncomplicated previous two cesarean sections,  uncomplicated present pregnancy and no contraindication to vaginal delivery.   unsuccessful vbac is due to increase BMI of the mother, fetal macrosomia, previous surgery interval of less than 2 years, previous 3 or more cesearean section, previous cesarean section due to labour dystocia, maternal short stature . Explain the risks and benefits of vbac after previous cesarean section . If the womens  previous cesarean was due to labour dystocia and CPD advice aganist vbac as it is associated with failed vbac and increased risk of emergency cesarean section . If the previous uterine incision was classical or J or inverted T and lower vertical incision advice aganist vbac as risk of intrapartum uterine rupture . this increases maternal and neonatal mortality and morbidity.  IF there was intrapartum and post partum infection and fever there is risk of scar dehiscence .  If the uterus was not closed in two layers during the previous cesarean section there is risk of uterine rupture . if the duration is less than 2 years from the previous cesarean section there is increase risk of scar dehiscence and uterine rupture . If previous one vaginal deliver the success rate of vbac is increased.  .There is 1% risk of blood transfusion and endometrities in vbac.  The risk of uterine rupture in vbac is 22-74% where there is no risk in ERCS.  There is increased risk of antepartum still birth after 39 weeks . Increased risk of birth related perinatal death in vbac compared to ERCS. About 8-1000 Increase risk of fetal Hypoxic ischeamic encephalopathy in vbac , long term data is not known. Respiratory morbidity is decreased by 2-3 folds compared to ERCS where it is increased to 3-4 folds .  the risk of uterine rupture, VTE, blood transfution, infection , haemmorhage is decreased in vbac .  Successful vbac does not limit the family if the women is planning a large family in future compared to ERCS . successful vbac is associated with quick postpartum recovery , shorted hospital stay .  Absolute contraindication to vbac are previous classical cesarean section , previous ruptured uterus , and three or more cesarean sections .  Tell the women she should have MDT involved in her antenatal care involving obstretician, anaesthetist, haematologist , midwife and GP .she has to deliver under consultant led unit where facilities for emergency intervension is possible . antepartum anaesthetic rewive is nessasary . delivery plan should  be discussed along with the consultant and documented in the notes at 36 weeks.  risk of uterine rupture with IOL with prostaglandins is increased from 2-10 folds . IOL  with oxytocin and AOL with oxytocin must be done by the consultant along with the women . , continous intrapartum  electronic fetal monitoring is needed . neonatologist must be present during delivery . Provide information leaflet  ,detail documentation about the discussion .  Take womens wishes into consideration .

B] Take history of spontaneous ROM .  The duration of rupture, if associated abdominal pain , any vaginal bleeding , the colour of liquor and smell, and feeling of fetal movements  . Examine the women by checking her pulse, temperature and blood pressure as risk of  intrauterine infection . palpate abdomen for fundal height , any small size for gestational age , any tenderness and FHR for risk of chorioamnionitis.  perform a sterile speculam examination to confirm ROM  ,we can see pooling of fluid in posterior fornix .  avoid vaginal examination as risk of introducing infection .  Do investigations such as FBC,CRP .HVS and endocervical swab .  urine for analysis.  USG to check for amout of liquor volume but this is  benifitted only in some . explain the diagnosis to the women  . admit the patient  in the  hospital for atleast  24-48 hrs. monitor her vitals such as temperature and pulse 4-6 hrly  .give her prophylactic erythromycin 250mg  to prevent infection.  fetal monitoring is done by CTG . There is no evidence to monitor fetus  with serial  growth scan and doppler.  tell her she will go into labour with in 24-48 hrs .  if the patient does not go into labour IOL by oxytocin can be decided by the consultant along with the women .  Prostaglandin IOL is associated with increase risk of uterine rupture .  If the patient is stable after 24-48 hrs and no signs of labour and any infection and wants expectant management  discharge her .   counsel her about the signs and symptoms  of chorioamnionitis .  if she feels unwell, feverish, change in colour of liquor, foul smelling liquor and change in fetal movements report to the hospital . provide her information leaflet and  24 hr contact number of the hospital.

vbac Posted by Ghida R.

 

A healthy 34 year old woman attends the antenatal clinic at 21 weeks gestation following a normal anomaly scan. She has two previous caesarean sections and wishes to have planned vaginal birth. (a) Discuss your assessment and counseling [15 marks].

I will check her previous deliveries whether she had a previous vaginal birth especially a previous vaginal birth after cesarean, as this is the single most important factor to predict a successful subsequent vaginal birth after cesarean. Her last delivery time should be checked as <2years interdelivery interval is associated with less successful VBAC. Her previous children birth weight is checked, and if marosomia is present i.e>4000g, she has a higher change of a macrosomic baby which is also assoicated with less chances of subsquent successful VBAC. The indication of previous cesarean delivery is important as dystocia is associated with a more failed VBAC. I will also check for time of previous deliveries as preterm cesarean deliveries are associated with less successful VBAC. Fever in the intra or postpartum period of a previous cearean is associated with a higher risk of uterine scar rupture, thus favouring elective repeat cesarean delivery. I will need to check  her previous operative notes to check for the indications of cesreans, type of uterine scar incisions as a classical upper segment cesarean is a contraindication to subsequent trial of VBAC due to higher rate of rupture. Extension of the uterine scar into the upper segment as in j or inverted t incision are also associated with higher risk of rupture. Other complications should be noted e.g previous uterine rupture which is also a contraindindication for VBAC due to higher risk of uterine scar rupture although no reliable estimates of rupture exist. I will also check for previous problems with the placental site e.g accreta as this may recurr in a subsequent pregnancy.

Her BMI and height should be checked as in BMI>30 and short stature are associated with less chance for successful VBAC. 

Provided this lady had two previous uncomplicated cesarean births, the option of vaginal birth after cesarean can be discussed only after review by a consultant obstetrician, and after reviewing the risks and benefits. the patient should be informed that subsequent vbac after 2 cesareans is not associated with significant increase in uterine scar rupture as compared to patients with one previous cesarean (90/1000 versus 70/10000 respectively). However she should know that she has increased risk for hysterectomy (60/1000 versus 20/10000) and blood transfusion 3.2% versus 1.2%. The rates of successful vbac are similar between and 2previous cesareans and 1 previous cesarean (62-75% versus 72-76%). No previous vaginal deliveries, BMI>30, previous cesarean for dystocia and induced labour are associated with less sucess of VBAC (collectively 40%). Planned vbac can be associated with increased perinatal mortality 4/10000, and with increased perinatal morbidity as hypoxic ischemic encephalopathy 8/10000, the long term effect of which on babies who experience it is unknown.

As regard benefits of Vbac it is associated with less respiratory problems at birth as compared to ERCS (1-2% VS 3-4% respectively).

she should be also counselled ERCS is assoicated with virtually no risk of uterine scar rupture when compared to VBAC (70-90 /10000). ERCS is associated with increased risk of serious complications in subsequent pregnancies(e.g placenta accreta, injuries to bowel, bladder, hysterectomy..).

There should be documentation of discussion of risks and benefits in the patient chart. A plan of management of delivery should be agreed between woman and consultant ideally by 36 weeks. it should include the method of induction or augmentation of labour, the interval of cervical assessment, the selected parameter for progress that would necessitate discontinuing VBAC. In the event of labour before scheduled date of delivery, there should be a plan documented also in the notes. patient should also be provided with clear written information as in patient pamphlets.

 (b) She presents at 39 weeks gestation with spontaneous rupture of the membranes but no uterine contractions. Discuss your antenatal management [5 marks].

the patient should be managed in suitably staffed and equipped delivery suite with continuous intrapartum care and monitoring, and available resources for immediate cesarean and advanced neonatal resuscitation. there should be multidisciplinary input (midwife, obstetrician, anesthetist, neonatologist, theater personnel, blood bank).

there should be continuous electronic fetal monitoring following onset of labour until delivery, as to detect abnormal CTG which is associated with 50-80% of cases of uterine rupture allowing for expedious delivery and resuscitation of mother and baby. As regard epidural analgesia it is not contraindicated and may be associated with increased successful VBAC. The use of intrauterine pressure catheter is not recommended as it doesn't add to clinical or CTG assessment of uterine rupture and its association with risks.

the use of augmentation or induction should be consultant led. there should be assessment of cervical progress preferably by the same person and this should follow the criteria sent by the consultant.

VBAC Posted by Kim M.

 

During my assessment I would take a detailed history including number of children and whether any of these children were delivered vaginally as previous vaginal delivery is the biggest predictor of successful vaginal birth after caesarean section (VBAC). I would enquire as to the weights of her previous children at delivery as fetal macrosomia is associated with a decreased likelihood of successful VBAC and also related to uncertainty about safety of VBAC. I would discuss the time between her last birth and this one as shorter interdelivery interval, particularly less than 2 years is associated with an increased risk of uterine rupture. I would undertake a comprehensive risk analysis for the indication and nature of the 2 previous caesarean sections, going through the operation notes if possible. I would want to ensure that the previous caesarean sections were done by routine lower segment incisions in otherwise uneventful pregnancies as otherwise VBAC would be contraindicated. Classical caesarean section incisions have the highest risk of uterine rupture but all uterine incisions other than routine lower segment incisions increase rupture rate. I would also find out the indications for the previous caesarean sections as if they were due to dystocia a future attempt at VBAC is likely to be unsuccessful.

I would counsel the patient about the pros and cons of caesarean sections versus vaginal delivery after caesarean section. I would explain that if she did want to go ahead with a vaginal delivery after two caesarean sections her care would be individualised and consultant led and her consultant would have to consider her suitable for planned vaginal delivery after reviewing all previous notes and having an in depth discussion with her. I would find out her motivations and preferences to achieving a vaginal delivery. I would discuss with her that the success of VBAC after having two caesarean sections is similar to after one at between 62-75% however she does have a higher rate of needing a blood transfusion (3.2%) and a hysterectomy though the rate is still low at 60/10000. I will discuss with her that her risk of uterine rupture after 2 caesarean sections is 92/10000 and if she chose to have another caesarean section this risk would be virtually zero, I would also advise that with VBAC her baby has a 2-3/10000 additional risk of birth related trauma and an 8/10000 risk of developing hypoxic ischaemic encephalopathy, which is a condition when the baby’s blood supply to an organ or structure is restricted, this can cause them to be on the special care baby unit however the effect of this on long term outcomes is unknown. I would advise that the risk of having problems relating to anaesthetic is low in both the VBAC and caesarean section groups and if she does deliver vaginally there is a lower risk to her baby of having respiratory problems after birth. I will ask about her family size and explain that if she does have a caesarean section this can increase her risks of delivery in the future as she has an increased risk of serious complications including placenta accrete, where the placenta infiltrates into the muscle of the womb, hysterectomy, bladder injury and blood transfusion. I will discuss with her risk factors associated with unsuccessful VBACs including induced labour, no previous vaginal deliveries, previous caesarean section due to dystocia and BMI over 30. Once we have finished the discussion I would document all aspects of counselling clearly in the notes and give her information leaflets regarding repeat elective caesarean section and vaginal birth after caesarean section. I will advise her that the final decision regarding mode of delivery should be agreed between herself and the obstetric consultant before the expected or planned date of delivery and ideally before 36 weeks.

I would review the notes to see what plan had been decided on by her consultant for mode of delivery. I take a history and ask about any foul smelling discharge, temperature or rigors which could indicate as infection as prelabour rupture of membranes can be associated with this. I would take observations including pulse, temperature and blood pressure as a tachycardia or raised temperature could indicate infection. I would also do an abdominal examination to assess fetal lie and position as this may change mode of delivery, I would perform an ultrasound scan if I was unsure of position. I would commence electronic fetal monitoring as to consider induction we would need to have a reassuring cardiotocograph (CTG). The CTG would also pick up fetal tachycardia which is another sign of infection. I would do an examination using a sterile speculum to confirm rupture of membranes and I would do a vaginal examination to work out a bishops score to help us guide method of induction or class of caesarean section depending on her prior management plan.  If this patient was booked for an elective caesarean section and not in labour I would inform the consultant on call and carry out a grade 3 emergency caesarean section. If this patient was scheduled for a planned vaginal delivery I would discuss her case with the consultant as the decision to induce, the method chosed and the time intervals for serial vaginal examinations should be discussed with the patient by the obstetric consultant and her care should be individualised. I would manage this patient in a suitably staffed and equipped delivery suite with continuous intrapartum care and monitoring and available resources for immediate caesarean section and advanced neonatal resus. There will need to be obstetric, midwifery, anaesthetic theatre, neonatal and haematological support continuously available. I would advise her to have continuous electronic fetal monitoring once in labour for the duration of the planned VBAC as abnormal CTG is the most consistent finding in uterine rupture. I will undertake careful cervical assessments and these would ideally be by the same person for labour to ensure there is adequate cervicometric progress thereby allowing the progress of labour to ensue. If induction was taking place I would titrate the oxytocin so that it should not exceed the maximum of four contractions in ten minutes. I would advise her that epidural is not contraindicated in labour and would explain to staff signs of uterine rupture to look out for including CTG abnormalities, vaginal bleeding of haematuria, abdominal pain particularly if it is persisting between contractions or shoulder tip pain or cessation of previous efficient uterine activity. If there were any signs of uterine rupture I would take her to theatre for a category 1 emergency caesarean section.

Posted by shereen S.

A)

i will ask her about the indications of her previous 2 c.s.if there are previous vaginal deliveries.As, this increases the sucess of vaginal birth after c.s ( VBAC). i will ask her also about the inteval between the previous delivery and this pregnancy.As short interval (< 2 years ) increases the risk of unsecussefual VBAC.If it is possible i will review her past operative notes to check if uterine rupture had happened in last pregnancy .moreover, i will check the type of the scar.As classical c.s is a contraindication to VBAC.if there are T or J extension to transverse incision. if there are perioperative complications as pelvic adhesions.i will ask her if she had fever or delayed wound healing as this refer to the strenghth of the scar.Moreover,I will ask her about any prevoius operation in the uterus other than cs, as myomectomy . i will ask her about the number of intended future pregnancies she wishes.

i will inform her that i will explore the risk associated with VBAC and elective repeated c.s (ERCS) . i will inform her that there is increased risk of uteine ruptue with VBAC, while no risk of it associated with ERCS.There are increased 1% additional risk of blood transfusion and endometrities.There are also increase risk of fetal complications such as birth related perinatal death associated with VBAC.on the other hand respiratory complications are more reduced than ERCS . As regard her wishes for future pregnancies i  will explore that ERCS associated with more risk of pelvic adhesion,placenta previa, accreta and VBAC will not be possible again.i will inform her that she will be reviewed and counselled again by consultant obstetrician at 36 wk to discuss with her plan of delivery.finally iwill provide her with written information about VBAC modified to after 2 c.s. and i will document the counselling in her antenatal notes. Also i will give her contact numbers if she has any worning symptoms of uterine rupture,As sever abdominal pain with tender scar. or /and vaginal bleeding.

B) i will ask her about what time PROM has happened,as sponteneous labour will start in the most of cases  in 24-48 hours. i will make general examination to check signs of chorioamnionitis such as fever and rapid pulse.i will make abdominal examination to check for uteine tenderness as it is associated with chorioamnionities. iwill check fundal height to assess macrosomic baby.check of and fetal poistion and presentation as malpresentation is a contraindications of VBAC. i will check fetal pulsation by ausculatation.Then i will make vaginal examination by sterile speculum to check the colour and odour of the liqour and if associated with meconium ,or if there is a cord prolapse. .i will discuss with the women that expectant managment  as in the most of the cases  spontenous labour will occure within 24-48 hours.i will inform her that induction of labour will carry additional risk for uterine rupture especially prostaglandine .  if she agrees with expectant management i will start prophylactic antibiotic as erythromycine  t..     .  Her labour will be under consultant led unit.she should be delivered in hospital with suitablly staffed and well equibed .under continous CTG and availabilty of emegency cs and advanced neonatal resusitation.

Essay 275 VBAC Posted by A A.

 

 

 

Ans . I shall take detailed obstetric history including her parity and any history of vaginal delivery or VBAC(vaginal birth after cesarean), which is the single best predictor of a successful planned VBAC. I will ask for indications of previous caesareans, gestational ages at that time, and time since last caesarean birth. Previous caesarean for dystocia, previous preterm caesarean and less than 2 years of interval since last caesarean all decrease the chances of VBAC .

I will do detailed general physical and systemic examination. BMI more than 30 kg/m2 , short maternal stature ,( and advanced maternal age,she is already 34 years of age) are also risk factors decreasing success rate. I ll go through previous case record for detail of operation, type of incision,and single or double layer closure of uterine incision Previous classical cesarean section, is a contraindication for trial of VBAC. Other variants, J , T shaped etc are also increased risk of uterine rupture. Transverse lower segment incision is most suitable type.Any history of intra partum or postpartum fever or wound infection during previous cesareans also increase the risk of rupture .

If she had previous two uncomplicated lower segment cesarean births, her current pregnancy remains uncomplicated with no contraindication to vaginal delivery, she may be considered suitable for planned VBAC at term, but only after discussion with consultant obstetrician. I will inform her that success rate of VBAC after previous 2 cesareans is 62 to 75% . comparable to that after previous 1 cesarean( 72 to 76%). I will counsel her regarding specific risks and benefits of VBAC vs.( Elective repeat cesarean section) ERCS . VBAC after previous 1 scar carries risk of uterine rupture of 22-74/10,000 deliveries, risk is higher for previous 2 ( no such risk with ERCS). VBAC also carries 1% additional risk of blood transfusion, 2-3/10,000 additional risk of death of baby, 8/10,000 risk of infant developing brain damage( hypoxic ischemic encephalopathy). VBAC reduces risk of respiratory problems in newborn .I will ask about her future fertility wishes and inform her that ERCS may increase the risk of serious complications in future pregnancies like placenta accreta, bowel and bladder damage.

Counselling will be documented in her notes and information leaflet given. She will be told that she needs to make final decision for mode of delivery after discussing with consultant obstetrician before planned/ expected date of delivery( ideally before 36 weeks) which will be documented., There should be a plan, if  labor starts before planned/expected date of delivery.( 10% cases ) .

 

b)She will be reassessed and notes rechecked for delivery plans. I will explain the diagnosis.She is asked about duration of ruptured membranes, fetal movements, fever, and foul smelling vaginal discharge. I shall check her, pulse , temperature,( to rule out chorioamnionitis)abdominal scar tenderness, color liqour , meconium and vaginal bleeding (to rule out any signs of scar dehiscence and fetal distress) . Vaginal swabs or CRP not indicated. Antibiotics only if signs of infection. She will be counseled regarding risk of infection to herself and her baby if duration of ruptured membranes is more than 24 hours . She will be told that more than 60 % of women go into spontaneous labour within 24 hours of ruptured membranes .She has options of expectant management, induction or cesarean section. She will be told about increased risk of uterine rupture (2-3 fold), and cesarean section if she needs induction or augmentation . Decision regarding further management will be discussed and agreed between her and the consultant after considering clinical picture and her wishes and preference. This is documented. Meanwhile she will be monitored regularly( according to agreed local protocol) for pulse, temperature,palpable contractions, uterine and scar tenderness, FHR, and color of liqour.  Ideally delivery should be planned after 24 hour if she does not go into labour.She will be managed  in a consultant led unit, with suitably staffed, well equipped delivery suite (If she wants to have trial of labour). She requires multidisciplinary team management, comprising of consultant obstetrician, anesthetist , neonatologist, hematology services and available resources for immediate cesarean section and advanced neonatal resuscitation.

 

ans vbac Posted by Mukta P.

(a)- My goals of assessment would be to find out her suitability for vaginal birth after cesarean section(VBAC). She has had previous two cesareans. i'd like to know details about these, esp, the cause for cesarean, to know if it was a recurring( like major uterine anomaly) or a non recurring cause(like breech),whether it was elective or emergency as complications are more if it was an emergency procedure, the reason like cesarean for dystocia can imply a poorer success rate of vbac. other details like any history of intraoperative( like extensions of uterine incision) or postoperative complication( like endometritis, wound dehiscence, blood tranfusion) would also give an indication about scar strength. the operative notes of previous sections should be reviewed , if available.

She should be counselled regarding increased risk of uterine dehiscence in labour(i in 200), need for continuous fetal heart monitoring(as helps in early detection of uterine dehiscence and risk of stillbirth), need for emergency cesarean section for fetal or maternal causes,risk of hypoxic ischemic enchalopathy in baby,.Success of VBAC is more if she goes in labour on her own, though the risks of above mentioned complications are more as she has had previous two cesareans.

(b)- i'd assess her abdominally to see symphysiofundal height for fetal growth, any contractions, confirm the lie and see if head is engaged. i'll do a CTG for fetal well being. do a speculum examination to confirm ruptured membranes.i'll counsel her regarding her options- if CTG is normal, liquor clear, average size baby, and she still wants a VBAC, she can await spontaneous onset of labour( thst usually happens in 60% of cases in 24 hours ),success of vbac is more if she goes in spontaneous labor(70%). if she does not go in labour , careful counselling by consultant obstetrician regarding induction of labour with syntocinon/prostaglandin will be made.i'll put in large bore iv cannula, take bloods for FBC and Gp n save. continuous monitoring of fetal heart once contractions start. partographic management of labour, and early recourse to cesarean section if delay in progress.

VBAC Posted by safwa mohamed el sayd E.

Detailed history &examination are needed to assess elegibility for VBAC, chance of success & any contraindication of vaginal delivery.I will ask about indication of previous CS( less success if due to dystocia,preterm cs).I"ll check age ðnicity,BMI, time lapsed from last cs (less cuccess if non white, advanced age, &>30BMI,short stature, <2 years ).History of any previous vaginal delivery,or successful VBAC increase chance of success 90%.I "ll review patient"s records to ascetain transverse lower segment uncomplicatedprevios cs as clssical cs, inverted T,J incision, complications such as scar rupture,dehiscense are contraindicated to vaginal delivery due to high risk of rupture & uncertain safty. Also I have to check the scan for any contraindication of vaginal delivery ( eg placenta previa,accreta) &reassess the woman near term for fetal size& scar tenderness.In case of transverse, lower segment uncomplicated previous cs in an otherwise uncomplicated pregnancy planned VBAC can be considered after counselling by obstetric consultant &a plan for delivery is agreed &recorded in her notes by36w. connselling of woman should consider her preferance , future plans of pregnancy,her chance of successful VBACbased on her assessment.Also she should be informed of risks &benefits of VBAC& elective repeat cs.VBAC risks include: scar dehiscence &rupture, Bl transfution, endomrtritis, neonatal hypoxic isckimic encephalopathy,increased perinatal mortality, possibility of failure &the need for emergency cs with increased risk of hysterectomy.However VBAC reduces risk of neonatal respiratory morbidity which is more with elective cs. Other elective cs risks include: increase chance of visceral injury (bowel, bladder), increased risk of placenta previa& accreta with possible hysterectomy. However it has the advantage of avoiding scar rupture, hypoxic ischemic encephalopathy less need for Bl transfution &less endometritis.written information should be given to patient to help her to have informed choice.

b) PROM with no uterine contraction in previous 2 cs, patient should be admitted for full assessment (abdominal ex for fetal size, scar tenderness, lie, presentation, engeged or not) CTG for fetal wellbeing. If  abnormal CTG, tender scar,estimated fetal wt >4kg,cervical dilatayion<4cm I'll recommend cs ,otherwise if patient declined I can awiat for spontaneous contractions for 24h after which I"ll recommend cs as the use of prostaglandines or oxytocin for induction carries high risk of complications with uncertain safty.

ans saq 275- VBAC Posted by Liza S.

 

SAQ 275- Ans
In this initial visit discussion and provision of information regarding her option of Planned VBAC should be done and she should be review at 36 week with the consultant appointment for the final decision regarding the mode of delivery which should be documented in the notes, and also a plan for the event of labour starting prior to the scheduled date should be discussed and documented. Counselling should be individualized by eliciting maternal preferences and future reproductive priorities. The  previous obstetric history should be assessed ,reviewed to assess the indication of caesarean section ,the type of incision and any complication at operation and after operation should be look in previous operative notes. Any history of vaginal delivery if present it is a single best predictor of successful VBAC. Inter delivery interval of less than two years is associated with unsuccessful VBAC. If in previous C-sections she as incision either than lower uterine transverse  like inverted T or J incision then it is a contraindication of planned VBAC ,also if she has a history of uterine rupture then it is a contraindication of VBAC. There is a 62-75% Successful rate of VBAC in this lady with a history of two previous C-Section. In planned VBAC the benefit are- a shorter hospital stay and recovery, and there will be increases like hood of future vaginal birth. In planned elective C-section the women able to plan to know the delivery date, less risk of blood transfusion and endometritis .Extremely low risk of uterine scar rupture in planned ERCS, also it will protect the pelvic floor injury and prolapse, and reduction of urinary incontinence .Option of sterilization if fertility complete. 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 but the rates of hysterectomy and transfusion are increased in the group of previous 2 C-section. Up to 25 % women trying VBAC have a chance of emergency caesarean; also chances of perineal tear and episiotomy are there.  In Planned ERCS she can have a 0.1- 2 % risk of surgical complications like inscion extension, ureter and bladder injury, and longer recovery time .Future pregnancies likely to require caesarean delivery, with increased risk of placenta previa /accrete and adhesions. The infant benefits of planned VBAC are the reduced risk of transient respiratory morbidity. Infant risks with planned VBAC should be explained to here, there will be increased risk of antepartum still birth beyond 39 weeks whilst awaiting spontaneous labour, and she has also an increased risk of hypoxic ischaemic encephalopathy of the infant in planned VBAC. There is also 0.04% risk of delivery related perinatal death for the infant is there in planned VBAC. In planned ERCS the risk of stillbirth beyond 39 weeks can be avoided.
(B) Send for FBC, blood group and save serum .Check her blood pressure, pulse and temperature. Ask her when she has a rupture of membrane, it is clear or blood mixed, or there is any foul smelling loss which can be a possibility of chorioamintitis. Ask about the fetal movement after rupture of membrane .Per abdomen examination checks the fetal heart and any tenderness. Explanation should be done that more than 90% women will go in labour within 24 hours of rupture of membrane. Discussion should done that in case she did not went in labour she has an option for induction of labour /or augmentation after 96 hour of rupture of membrane, but as she has previous two C-section this option is a relative contraindication with a high risk of uterine rupture with prostaglandin E2 induction, it should only be preceded by careful assessment by restricting the dose and adopting a lower threshold and maternal counselling by a consultant-led decision. She has also be informed that augmentation with oxytocin can be done with careful titration and assessment of cervical dilatation according to the protocol of the unit ,if she has no progress the delivery  option  will be a repeat C-section .
 
ans saq 275- VBAC Posted by Liza S.

 

SAQ 275- Ans
In this initial visit discussion and provision of information regarding her option of Planned VBAC should be done and she should be review at 36 week with the consultant appointment for the final decision regarding the mode of delivery which should be documented in the notes, and also a plan for the event of labour starting prior to the scheduled date should be discussed and documented. Counselling should be individualized by eliciting maternal preferences and future reproductive priorities. The  previous obstetric history should be assessed ,reviewed to assess the indication of caesarean section ,the type of incision and any complication at operation and after operation should be look in previous operative notes. Any history of vaginal delivery if present it is a single best predictor of successful VBAC. Inter delivery interval of less than two years is associated with unsuccessful VBAC. If in previous C-sections she as incision either than lower uterine transverse  like inverted T or J incision then it is a contraindication of planned VBAC ,also if she has a history of uterine rupture then it is a contraindication of VBAC. There is a 62-75% Successful rate of VBAC in this lady with a history of two previous C-Section. In planned VBAC the benefit are- a shorter hospital stay and recovery, and there will be increases like hood of future vaginal birth. In planned elective C-section the women able to plan to know the delivery date, less risk of blood transfusion and endometritis .Extremely low risk of uterine scar rupture in planned ERCS, also it will protect the pelvic floor injury and prolapse, and reduction of urinary incontinence .Option of sterilization if fertility complete. 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 but the rates of hysterectomy and transfusion are increased in the group of previous 2 C-section. Up to 25 % women trying VBAC have a chance of emergency caesarean; also chances of perineal tear and episiotomy are there.  In Planned ERCS she can have a 0.1- 2 % risk of surgical complications like inscion extension, ureter and bladder injury, and longer recovery time .Future pregnancies likely to require caesarean delivery, with increased risk of placenta previa /accrete and adhesions. The infant benefits of planned VBAC are the reduced risk of transient respiratory morbidity. Infant risks with planned VBAC should be explained to here, there will be increased risk of antepartum still birth beyond 39 weeks whilst awaiting spontaneous labour, and she has also an increased risk of hypoxic ischaemic encephalopathy of the infant in planned VBAC. There is also 0.04% risk of delivery related perinatal death for the infant is there in planned VBAC. In planned ERCS the risk of stillbirth beyond 39 weeks can be avoided.
(B) Send for FBC, blood group and save serum .Check her blood pressure, pulse and temperature. Ask her when she has a rupture of membrane, it is clear or blood mixed, or there is any foul smelling loss which can be a possibility of chorioamintitis. Ask about the fetal movement after rupture of membrane .Per abdomen examination checks the fetal heart and any tenderness. Explanation should be done that more than 90% women will go in labour within 24 hours of rupture of membrane. Discussion should done that in case she did not went in labour she has an option for induction of labour /or augmentation after 96 hour of rupture of membrane, but as she has previous two C-section this option is a relative contraindication with a high risk of uterine rupture with prostaglandin E2 induction, it should only be preceded by careful assessment by restricting the dose and adopting a lower threshold and maternal counselling by a consultant-led decision. She has also be informed that augmentation with oxytocin can be done with careful titration and assessment of cervical dilatation according to the protocol of the unit ,if she has no progress the delivery  option  will be a repeat C-section .