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MRCOG PART 2 SBAs and EMQs

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Essay 241 - VBAC

Posted by Shahla  K.
)assement should be consultant base so that identification of risk factors can be done.When Women with previous scar get pregnant then there are risks of another caeserian section,placenta praevia(acreta if anterior placed),excessive haemorrhage and blood transfusion.
History of previous pregnancy ,mode of delivery,indication for previous caeserian section should be of concern her notes of previous caeserian section should be examine. In the absence of nonrecurrant cause ,classical caeserian section ,and obstetric cofactor(multiple gestation)she can be a candidate for VBAC, Routine examination to assess women generally anemia should be check for iron supplementation earlier. Fundal height, type of scar noted.Routine complete blood picture,blood group,urine analysis send.Ultrasound for routine anomaly scan should be done.In the beginning of 3rd trimester scan to localize placenta is mandatory if placenta anterior covering lower segment then there arise concern for placenta acreta,which is difficult to discriminate on ultrasound. Women inform that she should deliver in hospital ,consultant led setting .written information about VBAC and caeserian section should be given.Plane of mode of delivery should be documented in antanatal notes preferably at 36 week .While women wishes should be taken into account.

b) I will tell her that with previous caeserian success of vaginal delivery is ̃̃̃̃̃̃60-80% but she is at high risk of repeat caeserian section,a planned caeserian section is far safer then emergency caeserian section.Emergency caeserian associate with higher incidence ofVTE,endometrites,and wound sepsis.Where as planed caeserian not only avoid those morbidities but also have protective effect on pelvic floor.
There is increase risk dehiscence of scar incidence30-50/10000.may need urgent laprotomy caries higher neonatal morbidity and mortality10/10000,she may bleed excessively, need massive transfusion of blood ,if bleeding uncontrollable hysterectomy may be needed.which is future fertility threatening.But these complications are rare.
c)she should be care in one to one midwife unit,should be consultant based with fascilities of blood bank. Intravenous excess establish ,blood need to be send for cross match and arrange and ,haemoglobin assessment for emergency.
Her vital sign(blood pressure ,pulse) check every 15 minute. Require continuous fetal heart rate monitoring which may confine her to bed .
progress in labour check every 2 hour, keep eye on scar tenderness Per vaginal losses.Features of dehiscence of scar include a change in perception of pain ,featal heart rate abnormality ,tachycardia falling BP,scar tenderness ,poor progress in labour,vaginal loss of blood and haematuria.For pain epidural analgesiais a good choice.Agmentation for poor progress is relatively contraindicated but can be use with extra more caution regarding watching for progress and given for short duration.

Posted by Mohammad H.
A healthy 32 year old woman with one previous lower segment caesarean section is referred

to the antenatal clinic at 18 weeks gestation. (a) Justify your clinical assessment [6

marks]. (b) What will you tell her about the risks associated with planned vaginal birth?

[9 marks] (c) She opts for vaginal delivery, has an uncomplicated pregnancy and presents in

spontaneous labour at 38 weeks gestation. Justify your intra-partum care [5 marks].



I will take history about the indication of previous caesarean sectoin ( c.s )and its

out come as if it is premenant cause vaginal delivery (v.d ) will not be allowed. Medical

history (hypertension,diabetes,cardiac problems)as this may affect the antenatal care and

the mode of delivery.I will review the operative notes of previous cs (if available ) to

review the indication ,the type of of CS\'lower or upper segment CS\" and any intraoperative

complications.History of puerperal pyrexia or sepsis as this may indicate scar weekness and

more difficulty on performing subsequent CS because of adhesions .I will assess the body

mass index (BMI) as if it is high it may be associated with scar weekness and difficulty

on performing CS. Abdominal examination to assess the scar type (transverse or

paramedian)and appearance of the scar . Anomaly scan at 20 -22 weeks to rule out any

structural anomalies.




About the risks of planed vaginal delivery (VD),I will tell her that successfull VD after

cs occurs in about 60% OF CASES .However there is an increased risk of scar deheisnce and

scar rupture .Scar rupture occurs more with upper segment CS.Rpture scar may lead to fetal

death, severe hemorrhage requiring blood transfusion and hysterectomy .
There is no guarantee for vaginal delivery if the patient opts for and emergency caeserean

section can be indicated at any time during delivery .
Information leaflets should be provided to the patient.




AS regard intrapartum care ,insure venous access and take blood for save and group as there

is increased risk of hemorrhage . Senior obstetrician,anaesthetist and neonatologist should

attend the delivery and should be aware for early detection and management of scar rupture

.Availability of theatre ,blood and rapid resort to CS if any difficulty in VD.Continuous

electronic fetal monitoring as fetal distress can occur due to scar deheisnce or rupture

.Avoid use of uterotonics as scar rupture can occur as a result of their use.
Posted by Saad A.
Detailed history is taken including LMP to ascertain her gestation age. Her previous obstetric history is obtained to determine the indication of previous C-section whether it was due to non recurrent cause like foetal distress, placenta praevia and breech. If she is not sure of the indication then previous hospital notes are obtained. Her current pregnancy notes are reviewed to identify any risk factors like hypertension,bleeding.Her dating and anamoly scan is also reviewed if performed. Examination is done to exclude malpresentation,multiple pregnacy,and assess amount of liquor , estimated weight of the foetus to exclude macrosomia. USG to exclude placenta praevia and multiple pregnancies.
b. I will discuss the benifits and risks associated with VBAC and ERCS(Elective repeat C-section) . I will tell her that VBAC is successful in 80-90% cases. There is less need of blood transfusion in VBAC. The risk of foetal hepatic ischaemic encepathlopathy is less. However the risk of rupture uterus is more than ERCS but it is only 22-74/100000. I will explain the relative contraindications to VBAC which include previous classical C-section in which case consultant view has to be taken. I will tell that there is slight increase of birth related perinatal deaths( 2-3/10000 )with VBAC but less risk of RDS than ERCS. Then I will explain that in case of multiple pregnacy and macrosomia foetus there is uncertainity in the safety and efficacy of VBAC. I will also tell her that in case of ERCS there is increased risk of serious complaications like placenta praevia, placenta accreta in the future pregnancy. I will discuss the IOL and that there is an increased risk of ruptured uterus with use of prostaglandins and increased risk of surgical intervention. There is risk of emergency C-section in 20% cases which is associated with increased maternal morbidity/mortality compared to ERCS. Her wishes will be taken and documented .She will be given written information .Her final decison regarding MOD wil be reviewed at 36 weeks .
c. During I/P care there is continous need of care by trained obstetrician and midwife .There is need of availablity of facilities for emergency c-section and neonatal resuscitation. Adequate need of analgesia (epidural) is required .Continous electronic fetal heart rate monitoring is required . Monitoring is done for any impending signs of uterine rupture (contant abdominal pain,vaginal bleeding, cessation of uterine contractions , loss of fetal heart, shoulder tip pain, breaking pain through analgesia). If these develop immediately laprotomy is needed after informed consent of the patient. The use of intrauterine pressure in early detection of uterine scar is not recommended. In case of failure of progress emergency c-section is required.
Posted by Sabahat S.
A) History of the previous CS ( ceasarean section ) is important. If possible the records of the previous CS should be available. Indication of the CS-was it a recurrent ( e.g CPD ) or non recurrent ( e.g fetal distress )?. At what gestation was the CS done ? if preterm CS, increased chance of scar rupture. Was it a lower segment vertical or J shaped, inverted T shaped (increased chance of dehiscence ). Was the postpartum period complicated with any fever ( endometritis ) ? increased chance of a weak scar. If less than 2 yrs since the last CS high risk of a weak scar & dehiscence. If the CS was followed by a successful vaginal delivery, the chances of success of VBAC are increased (85 ? 90) %. DM, obesity increased BMI, short stature, previous history of large baby or CS for dystocia, increase the risk of failed VBAC. Patient information leaflet is provided to her.
B) Short term risk associated with planned VBAC are perineal lacerations with associated risk of perineal pains, dyspareunia. Increased risk of 3rd & 4th degree perineal tear, especially with instrumental delivery ( esp. forceps ), with associated short & long term morbidity of urological incontinence & anal incontinence ( flatus & faeces ). There is an increased risk of uterogenital prolapse. There is a .2 - .7 % risk of scar dehiscence. About 10 ? 15 % of the cerebral palsy are due to intrapartum causes & in VBAC ther is a 10/ 10,000 risk of hypoxic ischaemic encephelopathy with long term neurological sequele.
There is a 8/10,000 risk of unexplained antenatal death at 39 wks + in a woman with previous scar. There is a 2/10,000 risk of birth related perinatal death ( similar to a woman who experiences her first child birth )
If she tries for a VBAC & fails, the risk associated with emergency CS are higher with increased morbidity &, increased risk of bowel & bladder injury,infection,haemorrage, VTE.
C) This is a high risk labour & should be conducted with facilities for emergency
CS,blood transfusion, neonatal resuscitation constantly available. On admission the patient is assessed regarding the fundal size, presentation (should be cephalic ), regularity & strength of contractions. PV ? the dilatation ( if more than 4 cm, increased chances of success of VBAC ) station, position, membrane status, meconium stained liquor, adequacy of the pelvis. Epidural is not contraindicated. There should be continuous electronic fetal heart rate monitoring. Blood should be sent for group, save +,- crossmatched . IV access with plain IV fluids should be obtained. Partogram should be charted to assess the progress in labour & regular assessment should be made to detect any evidence of failure to progress ( cause due to passage & passenger should be reminded by Emergency CS ).Consultant input is advisable.Constant support during labour is associated with favourable outcome. If inadequate uterine contraction is the causes, a cautious approach to augmentation with syntocinon may be taken but under constant & close supervision. Any CTG abnormality eg. prolonged deceleration or tachycardia or complaints of constant pain at the site of scar, even between contractions, fresh vaginal bleeding, blood stained urine, shoulder tip pain, breathlessness, loss of station of presenting part, any maternal hypotension or tachycardia is an indication of scar dehiscence and should be taken for emergency CS. In case patient delivers vaginally & is haemodynamically stable & normal PV loss ? there is no role for palpation of the scar integrity vaginally ? which may be deleterious.
Posted by Valerie T.
a) First, I would take an obstetric history to find out whether she has had previous vaginal deliveries and whether any of the vaginal deliveries were after the caesarean section. A vaginal birth after caesarean section (VBAC) is more likely to be successful, if there has been a previous vaginal delivery and even more likely if there was a vaginal delivery after the caesarean section. I would find out the indication of the caesarean section, the type of uterine incision and whether there were any perioperative complications. This is important because a vaginal delivery should not occur after a complicated caesarean section, for example, a classical caesarean section.
I would ask what her wishes and preferences are for the mode of delivery of this baby, whether she ould like a VBAC or elective repeat caesarean section (ERCS).
I would measure her weight and height and calulate the BMI. This is important because a raised BMI is associated with an unsuccesfal VBAC.

b) First I would tell her that there is a 72-76% chance of a successful vaginal birth after caesarean section (VBAC). If the vaginal delivery is not successful, her baby would be delivered by caesarean section. A vaginal delivery is associated with a lower risk of neonatal respiratory disease than delivery by caesarean section. However, the VBAC is associated with an increased risk of uterine rupture, in comparison to an elective repeat caesarean section (ERCS) where there is no increased risk of uterine rupture. Vaginal birth is associated with an increased risk of neonatal hypoxic encephalopathy. There is a greater risk of endometritis with a vaginal birth compared to delivery by caesarean section which would need to be treated with antibiotics. The risk of having a blood transfusion is also greater with VBAC than ERCS. I would provide an information leaflet to reinforce these facts.

c) The first step in the intrapartum care is to provide this care in a delivery unit that is well staffed with midwives, obstetricians, paediatricians, anaesthesists and theatre staff. There should be availability of a theatre in case an emergency caesarean section needs to be done. There should be immediate access to advance neonatal resusciation since there is a risk of neonatal respiratory problems and hypoxic enncephalopathy associated with a vaginal birth following caesarean section.

Since there are risks of uterine rupture, maternal haemorrhage and caesarean section, I would take blood for full blood count, group and save, and I would obtain venous access.

The patient should have continuous electronic fetal monitoring. This is important because there is a risk of uterine rupture and this may be identified by abnormalities in the CTG. The patient should have her own dedicated midwife, with continuous intrapartum monitoring. The reason for this, is that symptoms and signs of uterine rupture may develop. This condition is an emergency that requires immediate action to reduce maternal and fetal morbidity and mortality.

I would perform a vaginal examination to determine the cervical dilatation. Regular assessments of the cervix, strength and frequency of contractions should be made, preferably by the same person to ensure that the labour is progressing. If there is slow progress, I would offer augmentation of labour. However, the patient would need to be told that there is a 2 to 3 fold increased risk of uterine rupture with this process.

I would offer analgesics such as entonox, morphine and epidural.
Posted by Jancy V.
I would go through her old records and verify the indication of the previous cesarean, if it was done for some recurrent indications like contracted pelvis or prior uterine surgery, it contraindicates vaginal delivery this time. I would also verify operation notes for the incision used and any significant intraoperative or post operative complication encountered . I will find out the date of the previous surgery, as inter-delivery interval of less than 18 months carries higher risk of uterine rupture. I would verify her LMP, dating from early scans available, because proper dating is important for a case pf previous cesarean. Height, weight and BMI are important, as obesity and short stature carries a lower success rate of VBAC. I will also examine her fundal height, if it corresponds to dates or not. Ultrasound assessment will be done, because it confirms dates and also can help to assess structural anomalies of the fetus.
I will inform the woman that she has two options- planned vaginal birth and elective repeat cesarean section. Planned vaginal delivery following a lower segment cesarean has a 70-75% success rate, however it carries a 0.2 - 0.7% risk of uterine rupture, while women with repeat CS have no risk of rupture. However if detected early, there is very low incidence of neonatal mortality and morbidity associated with scar dehiscence and rupture. Obesity, short stature, fetal macrosomia, premature rupture of membranes, occipitoposterior position, previous cesarean done for dystocia, no previous vaginal birth, less than 2 yrs from previous birth ?all of these reduce the success rates of VBAC. I will inform her that she would be given an appointment to discuss with the consultant and to be assessed regarding the suitability of planned vaginal birth vs repeat Cesarean and a plan would be finalized by 37 weeks regarding the mode of delivery. Planned VBAC has higher rate of blood transfusion, maternal pyrexia, postpartum endometritis compared to elective repeat Cesarean. There is no difference in risk of thromboembolism, hysterectomy and maternal death in the two options. I will tell her that induction of labour with vaginal prostaglandin carries high risk of rupture and hence induction is done only in limited number of cases. If she gets into labour, she has to be constantly monitored with 1 : 1 care. I will give her written information regarding the risks of VBAC and repeat cesarean , so that she can think over it and make a combined decision along with her consultant regarding mode of delivery.
Planned VBAC should be conducted in a suitably staffed and equipped delivery suite, with continuous intra partum care and monitoring. There should be facility for immediate caesarean section and advanced neonatal resuscitation. Obstetric, midwifery, anesthetic, operating theatre, neonatal and hematological support should be alerted and be available throughout planned VBAC. I will admit this lady in labour room, examine her, discuss with her and redecide on mode of delivery and take an informed consent. At least two units of blood should be cross matched and kept ready. Following the onset of uterine contractions, there should be continous CTG monitoring. Epidural analgesia is not contraindicated, in fact it helps to relieve maternal anxiety. Partogram should be maintained and progress monitored. If there is any indication of slow progress ie, dilatation less than one cm per hour in spite of uterine contractions, decision for emergency Cesarean has to be taken. If there are features of uterine rupture like continous abdominal pain, vaginal bleeding, hematuria, loss of station, tenderness or hypovolemia, immediate resuscitation should be done and laparotomy arranged. If the woman progresses well in labour and reaches second stage, delivery should be conducted by an experienced obstetrician. Active management of third stage should be done to minimize bleeding. Routine exploration of scar is not done post delivery. The patient and relatives will be informed about the progress and notes will be clearly written about the events.
Posted by Parveen  Q.
I will ask about the indication for caesarean section,and any vaginal delivery after LSCS as the success rate for VBAC is 72-76%. If ther is no vaginal birth aftercaesarean section success rate is reduced to 40%. I will review her notes for indication, any perioperative complications and if it was done for term or preterm pregnancy, as success rate is less in the latter and also if here were perioperative complications. I will enquire her about her future pregnancy plans and her wishes will be considered. I will note down her BMI as BMI more than 30 is associated with reduced successr rate for VBAC. I will examine her abdominally to note down the fundal height . I will review her notes for early USS for gesatational age and and if she preferrs elective C.S , a provisional date written down in her case notes. If she is found to have twin pregnancy from uss report review of case notes, and considering for VBAC, cautious approach will be taken as there is no safety and efficacy data in such cases.

The risk for planned VBAC is the risk of uterine rupture, about 22-74/10,000, and there is an increase in maternal, perinatal morbibity and mortality if there is uterine rupture. There is an additional risk of 1% risk of blood transfusion and endometritis. There is no significant difference in the maternal mortality, hysterectomy, thromboembolic complications between VBAC and elective repeat C.S (ERCS). Perinatal respiratory morbidity is less in VBAC compared to ERCS. But there is an additional 2-3/10,000 birth related perinatal death with VBAC. The risk of anasthetic complications is low irrespective of opting for VBAC or ERCS . She will be given information leaflets, and delivery plan will be documented in her notes.

She will be admitted in the delivery suite where facilites are available for early recourse to caesarean section and advanced neonatal resuscitation are available. Consultant obstetrician, anasthetist, theater staff, paediatrician, haematologist will be involved in her care. 2-4 units of blood will be cross matched. For pain relief, she can have epidural anagesia as it is not contraindicated. continuous electronic fetal heart monitoring done through out as abnormal CTG is present in more than 50% of uterine rupture. Augmentation of labour is associated with 1.5%risk of uterine rupture. The decision for augmenation should be taken by consultant with discussion with the patient. Cervical assessment should be done preferrably by the same person to ensure adequate progress. The time interval for assessment and when to discontinue VBAC should be made by consultant in discussion with the patient. Routine use of intrauterine pressure catheters are not recommended for early detection of uterine rupture. There is no need for routinue prophylactic antibiotics. Active mangement of third stage of labour undertaken. Paediatrician to be present to resuscitate the baby.
Posted by Idris O.
a) I would start my clinical assessment by reviewing the patient\'s note. Her past obstetric history of successful VBAC is the most important factor at success in subsequent VBAC. The indication for the caesarean section is also important. A caesarean section performed in second stage for possible dystocia reduces the chances of successful VBAC as this tend to be recurrent. Additional information would include the fetal weight and if greater than 4.5kg reduces the chances of successful VBAC as successive babies tend to be bigger. The outcome to the baby especially if not alive may suggest there might be comobidity like diabetes mellitus or hypertension which needs treatment. This increases the intervention rates and reduces her chances at VBAC. In the index pregnancy, accurate GA determination is important with her dating scan to be able to monitor growth of the fetus. The number of fetus is important because multiple pregnancy is associated with increased intervention rate. If the patient is obese, she\'s is at risk of big baby,diabetes mellitus or hypertension and this increases the intervention rate and reduced the success at VBAC. The wishes of the mother for VBAC ialso determines the mode of delivery. I would provide her with information leaflet on VBAC.

b) The maternal risks associated with VBAC include scar dehiscence and rupture in labour. This is associated with bleeding, need for blood transfusion and caesarean hysterectomy.
There is increased risk of maternal death if rupture of the scar occurs. The fetal risks include fetal distress in labour, fetal hypoxia and fetal death. There is an increased risk of perinatal morbidity and mortality. Additionally, there is a risk of emergency caesarean in labour with risk of infection, bleeding,injury to bowel, bladder and ureter if lateral extension of uterine incision occurs during caesarean section or there is uterine rupture. There\'s risk of prolonged hospital stay, DVT, wound infection and wound dehiscence.

c) Spontaneous labour at 38 weeks increases her chances of successful VBAC. She would be assessed for regular uterine contractions and cervical dilatation to confirm she\'s in labour. Once in labour, a partogram would be commenced to monitor the progress of labour by clinical assessment and VE every 3-4h. I would site a venflon and obtain blood for group and save. This is because this is an high risk preganacy with increase risk of intervention due to risk of scar dehiscence and rupture. I would commence continuous CTG to monitor fetal wellbeing. I would discuss pain relief with her as epidural analgesia provide effective pain relief in labour. If intervention is required, it avoids the risks of difficult intubation and aspiration associated with GA. I would inform the anaesthetist about this impending delivery. If she develops slow progress in labour, I would do ARM . She can have oxytocin augmentation if there are no signs of feto- pelvic disproportion and the fetal heart rate is normal. I would ensure her contraction is 3-4/10minutes by palpation and there is no hyperstimulation. The use of intra-uterine catheter to monitor strength and frequency of uterine is associated with increased risk of infection and is not very popular. The risk of scar rupture would be discussed with the patient. I would monitor her for signs of scar dehiscence or rupture which include undue scar tenderness, continous abdominal pain, pain breaking through an epidural analgesia, shoulder tip pain from blood under the diaphragm. The clinical signs of scar rupture include vaginal bleeding, haematuria, cessation of uterine contractions, easily palpable fetal parts, fetal distress as evidenced by fetal bradycadia on CTG and maternal collapse(sweaty, tachycardia and hypotension). Vaginal examination may show receding fetal parts . If any suspicion of scar rupture,resuscitation an urgent laparotomy would be required to confirm the diagnosis. The consultant obstetrician would be informed to be present because may need repair or hysterectomy.If labour progressess normally,
then vaginal delivery is possible. After vaginal delivery, check no undue bleeding or symptoms and signs of scar rupture which may require treatment. I would observe her vital signs and bleeding after delivery. If she has a successful VBAC, it increases her chances of subsequent VBAC.
Posted by Fahima A.
a) I will first review her previous case notes to know the cause of her previous caesarean section (c/s). If the cause is recurrent like cephalopelvic disproportion she will not be allowed for vaginal delivery. But in non recurrent cause like breech presentation vaginal delivery can be attempted. The time interval of previous section should also be noticed. If it is less than 2 years the success of vaginal delivery is low.
Her obstetric history is very important in this pregnancy. If she has any vaginal delivery after that c/s the chances of successful vaginal birth is higher. Ethnicity has also play a role here as nonwhite population has less success rate of VBAC.
Examination should be done to see her height & BMI short stature & increased BMI are the risk factors for unsuccessful VBAC.
b) She should be given evidence based information regarding risks and benefits associated with VBAC both for mother & fetus.
The success rate of VBAC is 72-77%. The success are less with induced labor, after 41 weeks gestation, birth weight greater than 4000 gm, increased maternal BMI & short stature.
The planned VBAC carries a risk of scar rupture about 22-77/ 10,000. There is virtually no risk of rupture in elective repeat caesarean section (ERCS). VBAC carries 1% additional risk of endometritis or blood transfusion. There is no significant difference between hysterectomy, thromboembolism and maternal death. Anaesthetic complications are very low in both VBAC & ERCS. However ERCS carries serious complications in future pregnancy like placenta accreta, injury to bowel & bladder, hysterectomy, large amount of perioperative blood transfusion.
There are fetal risks as well. In VBAC perinatal death is 2-3/ 10,000 compared with ERCS. The absolute risk of such birth related perinatal loss is comparable to the women having their first child birth. Planned VBAC carries an 8/10,000 risk of infant developing hypoxic ischaemic encephalopathy. The effect of long term outcome of such infant is unknown. However the risk of respiratory problem is increased in ERCS than VBAC. There ERCS should not be performed before 39 weeks.
Information leaflet should be given to the patient.
c) I will admit her to the labor ward. Continuous electronic fetal monitoring should be started because abnormal CTG is the most consistent findings in uterine rupture and it is present in 60-90% cases.Early venous access should be obtained and blood should be sent for group & save. Epidural analgesia is not contraindicated. Continuous intrapartum care (1:1 midwife care) is necessary. Operating theatre, anaesthethetist, neonatologist, haematologist should be continuously available in case of emergency operation. Consultant obstetrician should be informed. Partogram should be maintained. If augmentation is required the decision should be from the consultant. If there is any signs of rupture like abnormal CTG , pain between contractions, scar tenderness, maternal tachycardia, hypotension, abnormal vaginal bleeding patient should be taken to theatre for emergency c/s or laporotomy. Routine use of intrauterine pressure catheter is not recommended as it may also associated with risk.




Posted by Dr Mamta D.
a) My clinical assessment will include her history, examination and review of her previous records for identification of risk factors in current pregnancy. In her case notes, indication and type of previous cesarean section is noted as previous cesarean section for cervical dystocia decreases the success of vaginal birth and previous cesarean section for recurrent cause like cephalo pelvic disproportion contraindicates vaginal birth while non recurrent causes ( breech, placenta previa) are not contraindications for VBAC.

Her detailed obstetric history is taken as previous vaginal birth after cesarean section increases the success of VBAC while previous cesarean section done at less than 2 years duration decreases the success of VBAC. History of previous myomectomy with opened uterine cavity is a absolute contraindication to vaginal birth.

In the examination. I would note her age and calculate her BMI as both advanced age (> 40 years) and raised BMI decrease the likelihood of successful VBAC. I would do complete GPE examination & do abdominal examination to assess fundal height.
I would review results of dating scan to confirm gestational age. I would ask her wishes and preferences about the mode of delivery whether she would like vaginal birth or elective repeat cesarean section.

b) I would tell her that there are maternal risks and fetal risks associated with planned vaginal birth after cesarean section. I will tell her that the success of planned vaginal birth is 72 ? 76% but the maternal risks include risks of scar dehiscence and rupture (0.2 ? 0.7%) which is further increased in previous classical cesarean section (4-9%). I would tell her that as a result of scar dehiscence and rupture, there may be increased risk of hysterectomy, blood transfusion and fetal death. I would tell her that risk of maternal death due to uterine rupture is 0.02 per 1000 and perinatal mortality (0.4 per 1000) is increased due to fetal distress, hypoxia, hypoxic ischemic encephalapathy and IUD.
Besides this there is increased risk of placenta previa and accreta as a result of previous cesarean section and increased risk of antepartum and postpartum bleeding.

Written information will be provided to her and her wishes will be taken into consideration.

c) During labour, she should be carefully monitored under consultant supervision. Delivery unit should be staffed with experienced midwives, Obstetrician, Pediatrician, and Labour Staff. There should be availability of operation theatre in case an emergency cesarean section needs to be done. I would assess her pulse , BP, Pallor and BMI. Any evidence of Tachycardia and hypotension should raise the suspicion of scar dehiscence or rupture.
Abdominal examination includes estimation of fetal size, assessment of lie and presentation and fetal heart rate. Per vaginum examination should be done to note the cervical dilatation, effacement, confirmation of vertex presentation and its station. Any meconium stained or blood stained liquor should be noted and adequacy of pelvis should be assessed.
Continuous CTG monitoring should be done and partogram should be plotted to detect any evidence of fetal distress and cervical distocia. In case of secondary arrest in labour, she should be managed by emergency cesarean section. Oxytocin augmentation should be done with caution. She should be reviewed by anesthetist for epidural analgesia. Pediatrician should be presentation for delivery.
Labour staff should be alerted to identify features of scar dehiscence or rupture which include FHR abnormality, suprapubic pain, feeling of fetal parts easily, cessation of uterine contractions, shoulder tip pain, and bleeding per vaginum. Decision for emergency cesarean should be taken if these are noted.

Posted by Malar R.
Her previous notes concerning indications for caesarean, type of uterine incision, intraoperative and post complications must be established. Also any complications in pregnancy and in labour must be checked. This will enable counselling as to whether vaginal delivery can be offered or an elective caesarean will be advised.Previous pregnancy complications might recur hence they must be known.Her BMI must be checked as in severe obesity it may be safer to have planned caesarean to avoid intrapartum caesarean at night times when staff levels are lower.Her views must also be explored to check if she has a preference for mode of delivery. The current pregnancy must be assessed so far , as in case of concerns, mode of delivery may be influenced.

Vaginal birth is a trial and is associated with a success rate between 60-80%. It is therefore difficult to predict if vaginal delivery will be possible or not individually. It is safe. There is a risk of 3:1000 of uterine scar dehiscence and rupture as the contractions happen. This may cause bleeding and abdominal pain in her.It may cause baby to be distressed in labour and require emergency caesarean section. There is a small risk (1:2000) of severe neonatal morbidity requiring special care unit admission and mortality.She would be advised to come to hospital when her labour starts and be monitored continously. If her vaginal delivery trial fails, caesarean section is associated with a higher risk of blood tranfusion, haemorrhage and deep vein thrombosis and pulmonary embolism.
Should a vaginal delivery occur, there is a risk of getting perineal tears similar to women who labour without a scar.

This lady needs to be in a consultant led delivery unit and be managed in a one to one care setting due to labour being high risk of complications.Also a senior obstetrician must be involved in her care in labour to detect and act on complications promptly.

In labour,an IV access should be inserted and FBC and group and save sent. This is to allow resuscitation in the event of haemorrhage due to scar rupture and in case a caesarean section is needed.

Maternal analgesia must be adequate to maintain maternal comfort.

The baby must be monitored continuously with a CTG as abnormalities of CTG are the most reliable indicators of scar rupture.
The mother\'s pulse, BP, liquor colour (for blood),urine (for haematuria), contractions and scar for tenderness must be monitored. These will raise suspicion of rupture if tachycardia is present ,in low BP , sudden loss of contractions and blood in urine or heavily blood stained liquor.
Maternal vaginal assesment , cervical dilatation, station and progress must be monitored by a senior obstetrician. This allows consistency in care.Also, lack of progress or signs of scar rupture will be managed promptly in this way.

Delivery must be conducted in the presence of experienced midwives and any trials of instrumental delivery must be undertaken by eperienced operators in theatre if there is uncertainty about the success. This will enable prompt caesarean if failed vaginal delivery and minimise neonatal complications due to delay in delivery.

In view of risk of post partum haemorrhage, intravenous syntocinon must be available and syntometrine given as part of third stage management.

Posted by Natalie P C.
A. I would first assess the context of her previous delivery from her history and review of her notes. If the reason for the CS was dystocia then success of VBAC is less. I would check and see if it was an elective or emergency CS, whether it was an induction of labour or spontaneous onset and though there is no evidence or predictability, I would want to know how far she progressed in labour. Peripartum fever in her previous delivery is associated with a 4 fold increased risk of uterine rupture. Non-white ethnic groups have an association with decreased success rates. I would want to know what incision was made on the uterus as after 1 classical CS, the recommendation is a repeat CS for delivery. If it was a lower segment then VBAC is an option If it was an inverted T or a J incision then a consultant needs to make a decision. Preterm CSs are associated with a reduced success of VBAC.
B. I would tell her that there is a risk of failure of VBAC requiring a Em CS in 25 % women. This risk is reduced in women who have a successful VD to 10% so if she succeeded this time she has an greater chance of success in a 3rd pregnancy. The second risk to note is that of uterine rupture or dehiscence. Risk is 0.7% after 1 CS. This risk is higher though with prostaglandin IOL 1% versus non prostaglandin IOL/augmentation 0.9% versus spontaneous labour 0.3%. There is an increased risk of blood transfusion 3% versus 1%. She must be informed of the increased risk of perinatal mortality including antepartum stillbirth at term compared to repeat CS. This risk though is comparable to a primiparous woman. There is an increased risk of endometritis. Risk of hysterectomy though is the same from VBAC compared with CS.
C. I would first ensure we have the appropriate staff, expertise and facilities to monitor this lady and proceed to Caesarean in an emergency if needed and neonatal resuscitation available. I would put in a large bore (16gauge) intravenous cannula and do a full blood count and group and save and she had a risk of bleeding, CS and transfusion. I would carefully assess her abdomen ( scar tenderness, contractions, head descent) and pelvis (head position and dilatation esp as dilatation >4 on admission is associated with better success). She needs continous CTG monitoring as an abnormal CTG is a sign of uterine rupture/dehiscence.
She needs regular VE assessment looking for signs of obstructed labour (caput, molding, non-descent, slow progress, malposition). Signs of rupture/dehiscence include sudden onset scar pain, pain persisting between contractions, chest or shouldertip pain, vaginal bleeding, CTG abnormalities, maternal tacycardia, hypotension or shock loss of efficient uterine contractions and loss of station of head.
Posted by Fahima A.
Dear Dr. Paul
I am sorry to write that you missed my answer to cheque.
Would you pl. cheque my answer.
Fahima
Posted by Dr Mamta D.
Dear Dr. Paul,
Kindly check my answer.