The woman\'s anxiety should be addressed and a plan of mode of delivery should be made according to her wish after detail discussion about risks of prolonged pregnancy, risks of induction of labour and risks of repeat caesarean section.
Her gestation should be reconfirmed by her dating scan as it is more reliable than her LMP. History of previous caesarean and any complication should be taken and previous notes should be reviewed if needed. Although clinical or radiological estimation of fetal weight is not accurate at this gestation, abdominal palpation should be done to identify grossly big baby, presentation and engagement of head. There is no role of pelvimetry to diagnose cephalopelvic disproportion.
She should be counselled that prolonged pregnancy beyound 42 weeks is associated with significant perinatal morbidity like meconium staining of liquor, fetal acidosis in labour, birth trauma, shoulder dystocia. Intrauterine, intrapartum and perinatal mortality is also increased. The commonly used fetal surveillance tests ( fetal kick count, CTG, scan, Doppler) donot reliably predict fetal compromise in prolonged pregnancy.
She should be counselled that rate of normal delivery after caesarean (VBAC) is 60-70% for non recurring cause as is the case with her. Induction of labour at 41 weeks is associated with reduction in perinatal mortality and morbidity. But risks are failed induction, scar dehiscense, emergency caesarean which is associated with more maternal morbidity.
If she agrees for trial of scar she will be offered a vaginal examination and sweepening of membranes which release prostaglandins and start the labour. A RCT has shown that this leads to increase rate of spontaneous labour and reduction in induction rate. But this is uncomfortable and unbearable to some women and is associated with blood stained discharge.
After ten days, if spontaneous labour is not started, induction will be done so delivery is achieved by 42 weeks. ARM and oxytocin infusion is associated with less risk of scar dehiscense than PGE2 gel which should be avoided. Epidural analgesia is not contraindicated in labour.
Labour will be monitored closely for signs of scar dehiscense and continuous fetal monitoring will be done.
In case she do not agree for induction increased antenatal surveillance is required. Weekly ultrasound estimation of amniotic fluid index and twice weekly CTG. Any reduction in fetal movements should be reported immediately and followed up by BPP and Doppler velocitometry of umbilical artery. Induction should be strongly recommended if fetal compromise confirmed.
She should be given leaflets about process of induction of labour .
Posted by Ebeinheizer S.
I would counsel her after reviewing her previous operative notes. If the breech was caused by uterine anomaly or large lower segment fibroid which has not been removed, Vaginal Birth After Caesar (VBAC) is not an option. Puerperial pelvic infection or endometritis in the past would also raise questions about the strength of her Casarean wound and Induction of Labour (IOL) should be decided with greatest caution. Relative contraindications for VBAC in the index pregnancy such as breech presentation, multiple pregnancy or severe IUGR would preclude VBAC/IOL.
I will explain to her that IOL to achieve VBAC is usually done after 41 weeks with PGE2 vaginal pessary or amniotomy with oxytocin infusion. All IOL carries a risk of failure needing Caesarean Section, more so for her as she has never delivered vaginally before. However, I would offer a membrane sweep which can stimulate spontaneous onset of labour if VBAC is desired.
I will counsel that IOL also carries a risk of uterine hyperstimulation which can cause fetal distress and uterine dehiscence/rupture. Risk of uterine dehiscence/rupture is 0.3% in spontaneous labour and 2.4% where prostaglandin is used for IOL. I will tell her in layman?s term which is less than 1 for spontaneous and 2-3 in prostaglandin IOL for 100 women in her situation. If hyperstimulation occurs, we can try S/C Terbutaline to treat it but in fetal distress or uterine rupture/dehiscence, Emergency Caesarean Section will be necessary. Uterine rupture carries risk of severe maternal and fetal morbity and mortality. Emergency Caesarean Section itself carries higher risk of infection.post operative fever, pain, bleeding needing transfusion, bowel/bladder injury, fetal injury and venous thromboembolism.
If labour ensues after successful IOL, I will counsel her that there is a 70% chance of successful VBAC but 30% might still end up with emergency Caesarean Section. She would need continous fetal cardiac monitoring and close maternal monitoring. Delivery has to be where facilities for emergency Caesarean Section is available.
It is also important that I also counsel her about the benefits of VBAC. The risks associated with anaesthesia and Caesarean Section are eliminated. Post-partum recovery is faster with less pain. Faster ambulation and return to daily activity can be expected. There is also reduced risk of abdominal adhesion formation and chronic pelvic pain. She may even try for another vaginal delivery in the future but not forgetting her age related risks.
I will counsel her, preferably with her partner, providing relevant leaflets on IOL/VBAC/LSCS. Careful documentation and delivery plan will be recorded. With her informed decision and after getting Consultant Obstetrician?s advice, I will organize for IOL or Caesarean Section date.
Posted by Vinayak B.
While discussing management for this patient risk versus benefit should be balanced. Patient should be counseled as antenatal , intrapartum stillbirth rate increases as gestation is increased. Still birth rate doubles at 43 weeks. Induction at 41 weeks does not increase cesarean section or instrumental deliveries. Additionally it decreses incidence of meconium stained liquor and meconium aspiration syndrome. It also reduces incidence of shoulder dystocia and neonatal complication due to associated macrosomic babies at advanced gestation.
If vaginal delivery is achieved , future chance s of normal delivery are increased. Furthermore chances of placeta previa/ acreeta are reduced due to reduction of number of cesarean sections.
The various methods of induction such as membrane sweeping , medical methods (prostaglandin/Oxytocin) are explained to patient . Sweeping of membranes gives minimal discomfort without increasing incidence of infection .Additionaly it also doesn?t increase incidence of scar dehiscence as compared to previous LSCS in spontaneous labour. Oxytocin and prostaglandin associated with hypertonic contractions with added risk of scar dehiscence in previous lscs. . Oxytocin also increases neonatal hyperbilrubinemia and maternal hyponatremia. .If she is not keen on induction , close monitoring for fetal well being is required with DFMC / bi weekly CTG / Liquour assessment by USG..Induction has to be done at 42 weeks gestation if she doesn?t go into spontaneous labour.
The decision of method of induction will be taken by consultant or senior person after assessing gestational age, presentation , and excluding placenta previa. Pre induction CTG is done which is followed by continuous CTG monitoring. Induction is done. in a labour ward with facilities for cesarean section. Anesthetist should also be informed. Frequent monitoring of uterine contraction and progress should be done . Signs of scar dehiscence such as maternal tachycardia, lower segment tenderness, hematuia, fetal distress are monitored. If there is delay or no progress or signs of fetal distress , lower segment cesarean section is required with prophylactic antibiotic and thromboprophylaxis.
Patient?s wishes are considered.and noted . Leaflets regarding methods of induction are given and follow up appt is arranged.
Posted by Freha Z.
I would review her notes to establish accurate gestational age by booking scan as menstual dates can overestimate gestational age. Any complication like infection in previous caesarean section that can increase the risk of scar dehiscence.
I would counsell her that several studies show 75% likelihood of vaginal delivery after one section.
Iwould also explain that risk of stillbirth from 37week onward is 1 in 3000 pregnancies, from 42 weeks onwards is 1 in 1000 and from 43 week onward it is 1 in 500 pregnancies. Therefore there is need to induce labour or do caesarean section to reduce risk of perinatal mortality.
She can be advised for a membrane sweep which can result in spontaneous onset of labour. Randomised trials show that membrane sweepening result in onset of labour in large proportions of women and it reduces the chances of pregnancy going beyond 41 weeks. Fetal surveillance is required with biophsical profile and weekly non stress test.
At 41 week one option for her is artificial rupture of membrane if cervix is favourable(Bishop score 6 minimum is required). It is followed by syntocinon to start contractions. But she should know that one to one monitering will be required along with continous fetal monitering because of risk of scar dehiscence and fetal distress. Waiting to start contractions to start spontaneouly without syntocinon results in increase risk of ascending infection.
In case of unfavourable cervix( Bishop score<6) induction with prostaglndin(PGE2) is an option. But there is high risk of scar dehiscence because it may induce hypertonic contractions as once administered it is difficult to control absorption. Therefore PGE2 induction is unsuitable in her case.
Failure of induction can lead to emergency caesarean section which is associtad with high mortality and morbidity campared to elective caesarean.
She can go for elective caesarean section. As it is major surgery it is associated with risk of haemorrhage , infection, thromboembolism and risks associated with anaesthesia.
All the information provided should be backed up by leaflets and she should preferably counselled along with her partner. She should be helped to make an informed decision.
Posted by Badi A.
in this case the gestation is not yet considered post mature , and the chances of her to go beyond is much less as the incidence of post maturity is about 10%.
general assessment for the vbac should be evaluated before discussing the iol.
if the patient is a candidate for vbac then a further discussion about iol is carried. various methods been used in iol shuold be explained with each spcific complications of each one .
risks of iol including hyperstimulation , rupture of the scar and faliure of induction should be explained fully.
epidural analgesia should be explained as part of antenatal preparation for labour.
