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MRCOG PART 2 SBAs and EMQs

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Essay 283 - VBAC

Posted by Farzana N.
a) The patient should be able to discuss her mode of delivery during antenatal period. She has the options of planned VBAC and planned ERCS.Benefits and risks of each should be informed and documented in her notes.Chances of successful vaginal birth are as high as 72-76%
Benefits of planned vaginal delivery are that she will not have the risks associated with operative procedure,such as hemorrhage ,infection and thromboembolism. ERCS will have impact on her future pregnanciesAfter two c-sections she would need to be delivered by c-section in future pregnancies.She will be at lesser risk of repeat c-sections and developing complications such as placenta previa or placenta accreta, injury to bladder ,bowel or ureter, hysterectomy and transfusion requirement.
b) Planned vaginal delivery is associated with risks to her and her baby ,in case it is unsuccessful She is at increased risk of scar dehiscence or rupture. The risk is 74/10,000 .It will largely depend upon the type of scar that she has .If she has a classical c-section scar,the risk is higher,~3-4%.Uterine rupture is associated with significant maternal and perinatal mortality and morbidity and she may even rquire hysterectomy.There is an additional 1% risk of blood transfusion or endometris with VBAC. There is an increased 2-3/10000 risk of birth related death of the baby.There is increased incidence of antepartum still birth from 39wks.The infant is at also at risk of developing hypoxic ischemic encephalopathy ~8/10,000.
c) She should be informed that her options are active management with induction of labor or planned ERCS ,or expectant management. If she wants expectant management,USS with BPP and regular CTG should be done for fetal assessment.
If she still opts for vaginal delivery, she would require induction of labor .Vaginal examination is done to assess cervical status.Labor may then be induced by either prostaglandins or oxytocin.Decision for induction or augmentation would be taken by consultant. Prostaglandin induction is associated with an increased risk of scar rupture,so dose and exposure would be restricted.Labor would be conducted in a well staffed and equipped delivery suite with continuous intrapartum care and monitoring and facilities for immediate c-section and advanced neonatal resuscitation.Labor may be augmented with oxytocin,but it should be titrated to achieve 3-4 contractions in 10min.She would be closely monitored for any signs of uterine rupture.Serial vaginal examinations for cervical assessment is necessary.Any delay or poor progress would prompt delivery by caesarian section.Clear information is provided regarding risks and benefits of induction and augmentation, so that she can make an informed decision ,which should be documented and consent obtained.



Posted by H H.
A healthy 35 year old woman with one previous lower segment caesarean section and no vaginal deliveries has been referred to the antenatal clinic at 20 weeks gestation to discuss mode of delivery. (a) What would you tell her about the benefits of planned vaginal delivery compared to planned caesarean section? [3 marks

I will tell her that planned vaginal delivery is associated with shorter stay in hospital, less post partum infection and pain compared to planned cesarean. Bonding with her baby is better and breast feeding is easier and better established than when having a cesarean.

b) What would you tell her about the risks of planned vaginal delivery compared to planned caesarean section? [7 marks]

I would tell her that planned vaginal delivery after cesarean VBAC , there is risk that it might end doing an emergency cesarean . I will tell her that there is risk of scar dehiscence that occur in around one in every 200 if she goes into spontaneous labour,this would go to 1 in 100 if she was induced by oxytocin and 1 in 50 if induced with prostaglandins. I would tell her that there is 1% risk of need for blood transfusion and same ratio of having endometritis ie infection of lining of endometrial and so need of prophylactic antibiotics (controverse). Perinatal death increased compared to planned cesarean and risk of hypoxic ischemic encephalopathy is 8/10,000 with later risk of cerebral palsy.I would give her written information regarding benfits and risks of VBAC.

c) She opts for planned vaginal delivery but remains undelivered at 40 weeks gestation. How would you counsel her? [10 marks]
I will enquire regarding her LMP and confirm her gestational age with the help of her notes if not sure of LMP via an early scan. I will take history regarding her previous cesarean, indication (recurrent or non), date (>2ys ago better success VBAC), type(classical contraindicate VBAC), and at which gestation done as to see wether a lower segment was formed or not. I will ask in her obstetric history if she had a vaginal delivery after the cs as this add to the success of VBAC. If all data point to success to VBAC I will counsell her regarding risks and benfits of VBAC. I will tell her that after 41wk there a gradual increase in perinatal mortality and morbidity with increase risk of cesarean section and operative delivery.There is increase risk of me conium staining of amniotic fluid and that her baby might inhale it and get chest problems. I would tell her that it is difficult to monitor the baby and predict that he is distressed and that intrauterine death can be sudden.I will advice ,that I will give her a week after her 40wk for her to enter into spontaneous labour as this gives the best success to VBAC and if she does not go into labour I will induce ,telling her the risks of induction. I would respect her wishes and so if she decline being induced after 41wk gestation , I would offer her a package of monitoring till delivery and documment all my counseling. I will tell her that wether she will enter into spont labour or be induced ,continuous electronic fetal monitoring is done .She is given written information regarding VBAC and risks of post term. The type of analgesia in labour will be discussed with anesthetist.
Posted by dr neelangini G.
a) Benefits of planned vaginal delivery would be less operative morbidity & mortality e.g low risk of thromboembolism, haemorrhage, infection , postoperative ileus. Vaginal delivery will save her from second & then successive caesarean sections in future and this would lead to less chance of having morbidly adherent placenta, placenta previa, adhesions, ectopic pregnancy in future. Planned vaginal delivery will reduce neonatal respiratory complications as compression of chest of foetus occurs while delivering through the vagina .
b) The risk of vaginal delivery after caesarean section , increased risk of scar dehiscence & uterine rupture that would be approximately .3 to .4 % (LSCS) which will increase both maternal and fetal morbidity & mortality. She may not go in spontaneous labour & she may require induction or augmentation of labour which will again increase the chance of rupture. Witth failed induction or with prolonged labour or with foetal distress she will require emergency caesarean section which will cause more thromboembolism, bleeding intraoperative, need for blood transfusion, infection, injury to bowel & bladder . Vaginal delivery may cause perineal tears which may lead to incontinence & longterm risk of uterovaginal prolapse. With vaginal delivery there is increased risk of endometritis and postpartum haemorrhage because of scar dehiscence or rupture. Vaginal delivery is associated with increased risk of neonatal mortality, stillbirth &hypoxic ischaemic encephalopathy.
c) I would like to discuss in details about the further management plans & options. I will provide information leaflets . I will tell her that there is possiblity of vaginal delivery with regular monitoring by CTG, u/s for estimation of amniotic fluid & estimated foetal weight, maternal assessment of daily foetal movement count, and condition of cervix(cervical score) .If all CTG & other parameters are normal, I would like to tell her that we may wait upto 41 weeks for spontaneous onset of labour . If not, choice for induction of labour with oxytocin - low dose regimen to be considered , if cervix is unfavourable we may go for intravaginal prostaglandin gel in presence of expertise and in well equipped set up . During labour,there should be continuous CTG monitoring & should be monitored by well trained staff .Anaesthetsia consultant , neonatologist , haematologist & Operation theatre staff to be well informed in advance for any emergency caesarean section. I will inform her that as pregnancy advances risk of unexplained stillbirth increases , and increased foetal weight will increase the risk of trauma, rupture of uterus & shoulder dystocia. Also there is more chance of oligohydramnios & foetal distress. I would like to tell her that during the process labour she may require emergency caesarean section because of foetal distress, prolonged labour, scar dehiscence
Posted by Ahmad A.
I would tell to this lady that her hospital stay will be significantly shorter with vaginal delivery. Also the incidence of deep venous thrombosis will be lower than those with cesarean section(CS) Also she will avoid all hazards of CS like, post partum endometritis and wound problems (Dehesince and infection). She is going to avoid all future risks may suffer as a result of repeated CS and creation of adhesions especially for urinary bladder and bowel. On the other hand, the incidence of neonatal transient tacnypnoea (TTN) will be significantly lower than those with elective repeated CS.

Planned vaginal delivery has indeed some risks. Firstly, there is higher risk of scar rupture than others with no previous scars. However this will depend upon the type and indication of previous CS. Also this incidence will become higher in case of induction of labour according to the method used. So, the complications as a result of Prostaglandin (PG) are higher than Syntocinon. The operative vaginal delivery will be higher and the sequences from vaccum delivery like cephalohematoma and Forceps delivery like neonatal facial nerve trauma. Also, increase of maternal morbidity like vaginal tears, third and fourth degree perineal tears, pelvic floor trauma, faecal and urinary incontinence. I would tell her that she may need an emergency CS after failure of VBAC, in this condition there is high rate of neonatal morbidity, DVT, infection, haemorrhage and hazards of general anesthesia.


I would re-discuss with her the pros and cons of the VBAC. On the other hand, I would discuss with her the hazards of post maturity over her fetus. I would tell her that the gestational age limit without higher incidence of foeatal mortality. I would advise her that 41-42 weeks gestation is the time limit for delivery without complications. Also, I would discuss with the option of induction of labour (IOL). The decision of IOL will highly depend upon the condition of the cervix (Bishop\' score) This may happen through sweeping of membrane, rupture of membrane, oxytocin infusion or prostaglandin. Oxytocin will increase the incidence of rupture scar to 1.6/1000 however in spontaneous VBAC will be about 0.8/1000. While in case of PG-IOL the rate of rupture will be 2.4/1000. Also, the rate of rupture will be affected by the type of previous scar as, with previous J incision the rupture rate will be about 4/1000, lower vertical and inverted T incision will be 9/1000 and previous classical incision will be about 10-15/ 100. So, there is absolute contraindication of VBAC with cases of classical previous scar. I would advise her to have more closer follow up and monitoring of foetal movements and tracing of foetal heart if she wish after 42 weeks gestation. I would document all options given in the file and I would provide her patient information leaflet explaining the different corners of discussion.

Posted by S D.
a) I will explain that VBAC has implications for future pregnancies, subsequent vaginal delivery increases. It avoids anaesthetic risks, lower incidence of endometritis(1-2%) compared to repeat C/S (2-3%). It also avoids injury to bowel, bladder and allows quicker recovery.
b) The risk of uterine scar rupture is 72-74/10,000. This needs emergency laparotomy and sometimes hysterectomy. It should be explained that the risk of uterine scar rupture increases by 3-fold if IOL is required. There is a higher risk of perinatal death of 2-3/10,000 and hypoxic ischaemic encephalopathy of 8/10,000 compared to ERCS. There is a higher need for blood transfusion; risk of failure of VBAC warranting emergency C/S which is associated with higher perinatal morbidity and mortality. She is also at risk of uterovaginal prolapse, urinary incontinence and perineal pain. Written information should be provided and clear documentation made in the notes.
c) I will enquire about fetal movements and symptoms of labour such as abdominal pain and mucosy show. abdominal examination to check fetal presentation, size of fetus, engagement of head and fetal heart should be checked. Vaginal examination should be done to assess bishop\'s score. If the bishop\'s score is unfavourable, I will advise re-examination in a week\'s time. If still unfavourable, caesarean section should be recommended. If favourable, I will explain that spontaneous labour increases the chance of vaginal delivery. IOL with prostaglandins increases the risk of uterine rupture to 240/10,000. IOL with non-prostaglandins (ARM) increases the risk of uterine rupture to 80/10,000. Once in labour, continuous electronic monitoring of fetus should be done as CTG abnormalities is the first sign of uterine dehiscence. Partogram should be maintained and serial vaginal examinations at pre-determined intervals to assess progress in labour. If slow progress, then caesarean section will be performed. Information leaflets should be provided and woman\'s wishes should be respected. Clear documentation in the notes about the counselling should be done.
Posted by shree D.
STA
healthy 35 year old woman with one previous lower segment caesarean section and no vaginal deliveries has been referred to the antenatal clinic at 20 weeks gestation to discuss mode of delivery. (a) What would you tell her about the benefits of planned vaginal delivery compared to planned caesarean section? [3 marks]
i would inform her that the risk of neonatal respiratory problems is lower (1-2% compared to 3-4% with CS). She will be able to go home after a planned vaginal delivery, as opposed to a Caesarean section where she must stay in hospital to recover. The success rate of planned vaginal deliveries is 72-75%. The risk of bowel or bladder injury is lower with a vaginal delivery than Caesarean section, and a second Caesarean section is associated with a higher complication rate in future pregnancies(eg. placenta preavia , hysterectomy). She will be able to mobilise earlier following a vaginal delivery, and will be at lower risk of thromboembolic disease.

(b) What would you tell her about the risks of planned vaginal delivery compared to planned caesarean section? [7 marks] (c)

I would tell her that the risk of uterine scar rupture is 74/1000 vaginal births. Both she and the baby would be monitored in labour (maternal BP, HR, temperature), and fetal CTG in order to watch for signs of uterine scar dehiscence. The risk of HIE is higher in a vaginal delivey. There is no guarantee that she will have a successful vaginal delivery, and if so, the risks of an emergency CS are higher. She may have regional anaesthesia, and will need cannulation and bloods for FBC and G&S in labour. Overall, there is a higher perinatal risk of death with vaginal birth after a CS, with a 2% greater risk of endometritis and blood transfusion


She opts for planned vaginal delivery but remains undelivered at 40 weeks gestation. How would you counsel her? [10 marks]
I would review her in the antenatal clinic and counsel her on the benefits of an induction of labour at 41 weeks. The reason for inducing her at 41 weeks is to prevent the risk of stillbirth associated with prolonged pregnancy. I would offer her a cervical sweep in clinic, to stimulate labour prior to induction. I would discuss the options of elective CS or induction of labour at 41 weeks. Induction of labour would occur on delivery suite, and involve a baseline CTG and a vaginal examination. She would be cannulated and baseline bloods (FBC, G&S) performed. If possible her membranes would be ruptured artificially. She would have regualr obs (BP, HR) and a continuous CTG, to monitor for signs of scar dehiscence. Once in labour, she would have regular vaginal examinations every 2-4 hours. If she does not have any contractions, oxytocin infusion can be considered. However, she must be examined regularly every 2-4 hours to ensure that she is making adequate progress in labour using a partogram. If not, she will need a CS. If she cannot have her membranes ruptured, a CS would bediscussed with her. The possibility of needing an instrumental delivery should also be discussed with her. If she opts for a CS, she is more likely to have further complications in her future pregnancies, such as placenta praevia. After the delivery, she will receive im syntometrine and a syntocinon infusion and have an active third stage.
Posted by shree D.
Sir,

Sorry-my figure says 74/1000 vaginal births risk of scar dehiscence, should be 74/10000!!!
Posted by Neelam A.
a)She should be counselled that 72-74% would delivered vaginally following planned vaginal delivery.
Vaginal delivery follows early mobilization, quick recovery, short hospital stay, less analgesics requirement, quick return to work and low cost to NHS.
Vaginal delivery is associated reduced anaesthetic and operative risks, although risk of serious complications of anaesthesia is extremely low.
Future pregnancy outcomes improve following Vaginal delivery. There will be increase chances of having vaginal delivery in future. Incidence of placenta praevia and accreta increases with increase in number of caesarean section scars.
There will be 2-3% respiratory problems in neonates compared to 3-4% following caesarean births.
b)Planned vaginal birth results scar dehiscence in 22-74 per 10 000 in labour, hence she would need continuous electric monitoring.
Vaginal birth increases 1% additional risk of receiving blood transfusion.There would be 1% additional risk of endometritis following vaginal birth.
1-2 per 10 000 birth related perinatal death in women who considering vaginal births.
She should be informed that vaginal birth carries 8 per 10 000 risk of hypoxic ischaemic encephalopathy (HIE) compared to planned caesarean sections. Effect on long term outcome o infants experiencing HIE is not known.
She should be told that final decision should be made after considering her wishes.It should be documented her notes.
c)Cervical assessment should be done at 40 weeks if she remains undelivered. If cervix is favourable then sweep and stretch should be given after discussion and agreement with her.
If cervix is unfavourable, pros and cons of conservative versus prostaglandin induction should be discussed.
This discussion should be noted down in her notes and information leaflets should be provided.
She should be informed that there is higher risk of rupture uterus with induction of labour with prostaglandins.
There is 2-3 fold increased risk of rupture uterus in induced labour.There is 1.5 fold increased in risk of caesarean sections.
For induction local protocols should be followed. This induction would be high risk. It should be done on labour ward with facilities of emergency caesarean section and blood transfusion.
Continuous foetal monitoring is recommended to detect early signs of scar dehiscence. Epidural analgesia can be given.
If she opts for conservative option we can wait up to 42 weeks. After 42 weeks it has been shown to be associated increased stillbirths, intrapartum asphyxia, meconium staining and perinatal mortality and morbidity. Hence we should recommend increased foetal surveillance.

Posted by Manoj Babu  R.
a.

She should be told that success rate of planned vaginal birth is about 75% even though; in her case it may slightly lower as is not having any vaginal deliveries in the past. Women should be told that babies delivered by vaginal birth are less likely to have respiratory problems compared cesarean sections. She should be told that her risk of developing complications like pulmonary embolism, infections will be less following vaginal birth. She will be having fewer complications in future pregnancies, like the need for caesarean sections placenta previa, placenta acreta and postpartum hysterectomies for severe bleeding.

b.

The main risk is risk is of scar dehiscence and rupture which can occur in less than 1% cases. But it can cause major complications to the mother and baby. Maternal complications include haemorrhage, shock, need for hysterectomies and in extreme cases maternal death. There is also increased risk of blood transfusions and poastpartum endometritis.

Fetal complications include hypoxic ischaemic encephalopathy, birth asphyxia and perinatal death. But these are rare as she will monitored carefully during labour. She may need an emergency cesarean section if any thing goes wrong during labour. But it is associated with higher risks compared to a planned elective cesarean section. She should also be told that a planned elective cesarean section carry almost no risk of uterine rupture.

c.

She should be told that most of the women deliver within one week before and after the EDC. So there high chance that she will also go into labor. She should be offered a vaginal examination for cervical assessment a stretching and sweep of the membranes should be done after making sure that the placenta is in the upper segment. If the cervix is closed massage can be given through the foirnices. She should be told that it may increase the chance of her going into labor without any major side effect other than slight discomfort during the procedure. She should be told that there is slightly increased perinatal morbidity and mortality after 40 weeks it is more significant after 41 weeks and certainly after 42 weeks.

I will tell her that she will seen again at 41weeks if she remains undelivered and the options at that time includes an elective cesarean section, induction of labour or conservative management. The benefits of induction of labour include lower perinatal morbidity and mortality and reduced need for cesarean section compared to expectant management. But induction in the presence of a uterine scar is associated with higher risk of scar rupture compared to spontaneous labour and the increased need for emergency cesarean section. An elective cesarean section can avoid these complications.

I will also discuss the need for extrafetal surellance if the pregnancy goes beyond 42 weeks of she opts for expectant management. She should made aware of the possible rrisks and benefits and the final decision should be made by the women.

Posted by Dr Dyslexia V.
X

a. Planned vaginal delivery is recommended as it success rate is between 72 – 76 % after an uncomplicated single caesarean section. The advantage includes decrease in incidence of respiratory distress of the neonates. It also decreases the incidences of further complication of added caesarean section such as placenta previa and accrete. It also decreases other morbidity associated with an operation such as wound infection,and catheter infection. Other advantage includes shorter hospital stay. The decrease cost of delivery is also an added advantage.

b. The risk of planned vaginal delivery include risk of uterine rupture ranging from 22-74 per 10000. The risk of endometritis and unplanned blood transfusion is increased up to 1 %, the risk of serious perinatal morbidity, the risk of sudden still birth, the risk of hypoxic ischaemic encephalopathy is also increased. The risk of unplanned , emergency caesarean section which increases morbidity. The risk of urinary tract injury causing long term incontinence increased, lower genital tract trauma which could result in anal sphincter dysfunction is also increased.

b. She should be counseled based on her wishes which is an attempt for vaginal delivery. She should be assured that there is possibilities for her to go into spontaneous labour in the next two weeks but the success of rate decreases after 40wk. She should be aware the risk in increased neonatal morbidity, still birth and meconium stained delivery increases. She should be offered for prostaglandin induction with bearing in mind the risk of uterine rupture and the need for an emergency caesarean section. She could also offered close fetal monitoring with wipe and stretch and an induction at 42 weeks. She should also be offered to change her mind for an elective caesarean section after counseling with the risk and valid consent.

Posted by A S.
am

a) Benefits of planned vaginal delivery include shorter hospital stay ,less pains and rapid return to normal life activities. Respiratory problems in the neonate are less in planned vaginal delivery with incidence of 2-3% compared with 3-4 % in elective CS.
If she delivered vaginally the risks of placenta preavia and accreta , damage to bladder and viscera and blood transfusion of 3 to 4 units will be reduced in future deliveries .

b) On the other hand vaginal delivery after CS carries a risk of uterine rupture in 22-74 /10,000 . She must know that uterine rupture is a serious complication that necessitates immediate operative interference and carries a risk of neonatal morbidity and mortality . Risks of endometritis and blood transfusion increase 1% . There is more risk of delivery related neonatal loss 2-3 /10,000 in planned vaginal delivery . The risk of brain damage to the neonate ( hypoxic ischeamic encephalopathy ) is increased 8/10,000 . The need for emergency CS in 25 % of patients must be explained .

c) Now that she is 40 ws I will explain the risks of prolonged pregnancy like diminished liquor , diminished placental perfusion and muconeum staining of the liquor . Her choices are expectant management , induction of labour or elective CS. Expectant management will include offer of membrane sweeping if possible at 41 ws and twice weekly CTG and u/s to assess deepest pool of liquor beyond 42 ws
Induction of labour in her case carries more risk of scar rupture and need for emergency CS . Use of prostaglandins is especially associated with increased risk of rupture uterus so we can use amniotomy with syntocinon infusion but the efficacy in inducing labour is less . Induction of labour is more painful but she will be offered epidural analgesia which may increase the success rate of vaginal delivery . .
Evaluation by consultant obstetrician is a must to revise the decision and determine the method of induction . Intrapartum progress will be watched very carefully for signs of rupture uterus . She will be provided with written information leaflets and contact numbers .
Posted by Manoj M.
A healthy 35 year old woman with one previous lower segment caesarean section and no vaginal deliveries has been referred to the antenatal clinic at 20 weeks gestation to discuss mode of delivery. (a) What would you tell her about the benefits of planned vaginal delivery compared to planned caesarean section? [3 marks] (b) What would you tell her about the risks of planned vaginal delivery compared to planned caesarean section? [7 marks] (c) She opts for planned vaginal delivery but remains undelivered at 40 weeks gestation. How would you counsel her? [10 marks]

a) I will tell her about the benefits of a sucessful planned vaginal birth after caesarean section(VBAC) is a vaginal delivery (including instrumental deliveries) this happens in approximate every 3 out of 4 women choosing VBAC.
This will avoid the need for a surgical caesarean delivery which means avoiding complications of caesarean section, shorter recovery period and less pain.
There is a greater chance of uncomplicated births with future pregnancy when she has a sucessful VBAC this time.

b)The risks involved with planned VBAC includes an unsucessful VBAC which occurs 1 in every 4 women choosing VBAC and most of the risks occur with failed VBAC.
There is a 0.5% increased risk of uterine scar rupture or dehiscence with VBAC compared with elective repeat caesarean section(ERCS) This risk of scar rupture or dehiscence is increased if she needs induction or augmentation of labour.
There is a 1% increased risk of either blood transfusion or infection of uterus associated with VBAC compared with ERCS.
There is a 0.2% increased risk of brain damage to the baby with VBAC which is similar risk associated with first time deliveries (0.1% for ERCS)
Written information should be provided.

c)She should have her counselling session organised with a multidisciplinary approach involving consultant decision with a non-directive approach.
She should be fully involved in her decision making for the mode of delivery and her wishes considered to improve he outcome of care.
She should be given all possible options which include await spontaneous onset of delivery as there is a increased chance she may go into spontaneous delivery.
She could be offered with membrane sweep as a option so that she may be able to avoid induction and repeat caesarean section and for cervical assessment for favourability if requiring induction.
If she does not go into apontaenosu labour by 41-42 weeks options of induction of labour should be discussed but this may reduce the sucess outcome of vaginal delivery with increased risk of scar rupture with induction.
She should be told about the risk of scar rupture with spontaneous onset of labour in VBAC is 0.5% and this increases to 1% with oxytocin induction and 2% with prostaglandin induction of labour.
Alternative option is elective repeat caesarean section but associated with risks of caesarean section which include increase risk of thrombosis, longer recovery, need for future caesarean deliveries and a small increase in breathing problem for the baby with ERCS compared with VBAC.
If she cooose for repeat caesarean section she should be explained that she may still go into spontaneous labour while awaiting her elective section.
Her choice of mode of delivery and the consultations final plan should be clearly documented in her notes.
She should be provided with written information.
A further clinic appointment at 41 weeks should be organised if she dosent goes into spontaneous labour.
Posted by Mark D.
Mark d


The benefits of VBAC are early recovery post partum and less need for analgesics.The neonatal respiratory morbidity is lower (2-3%) in VBAC as compared to elective repeat cesarean section ERCS (3-4%).
In future pregnancies there is increased risk of CS if ERCS opted. With successful VBAC the chance of successful mvaginal birth in next pregnancy is 80%.



Planned vaginal delivery carries a risk of rupture of 22-74/10000 as compared to nil with ERCS.there is 1% additional risk of endometritis and blood transfusion than ERCS. The delivery related perinatal death rate is slightely higher 4/10000 for VBAC as compared to 1.4 for ERCS. There is 8 in 10000 risk of hypoxic ischemic encephalopathy due to intrapartum hypoxia with vaginal birth compared to almost nil with CS. There is no siginificant difference in rates of hysterectomy, maternal mortality and venous thromboembolism in both modes of deliveries.
How ever in cases of unsuccessful planned vaginal birth the risk of scar dehiscence, blood transfusion ,need for intensive care, hysterectomy as well as venous thromboembolism are all increased as compared to successful VBAC.
With vaginal birth there is a chance of instrumental delivery (15%),risk of perineal trauma like 3rd or 4th degree vaginal tears with have increased morbidity and affect quality of life. There is also increase in vioding dysfunction and pelvic floor laxity with vaginal birth.



I will review her plan of delivery made at 36 weeks and reconfirm that there is no contraindication for vaginal birth. I will ask if she has any complaints. I will tell her that she has option of elective cesarean section, induction of labour or expectant management. The fetal condition shall be monitored by CTG and amniotic fluid volume . if it is nonreassuring then I would recommend delivery by CS. However if it is ok I will offer a pv examination and membrane sweep to her after explaining about the procedure. I will tell her that it may reduce the need for formal induction of labour. She should report to delivery suite as soon as she gets into labour.
If she is undelivered by 41 weeks then an induction of labour can be done with prostaglandin vaginal tablets or vaginal gel.they are not licenced for previous CS cases in UK. However it carries a 2-3 fold increase risk of rupture uterus and 1.5 fold increase risk of CS as compared to spontaneous onset VBAC. Her delivery will be in a consultant unit. She will require close monitering of her vitals and continous CTG monitering in labour. 4 hourly vaginal assessments would be done to assess the cervicometric progress and if any signs of rupture seen CS would be necessary. Such decision of induction, the method of induction, frequency of monitering and the likely outcomes shall be discussed with her by the consultant.
Posted by Priti T.
prt

a]Various benefits of planned vaginal delivery should be explained to the patient.she can be told that there is 72-76%chance that she can have VBAC.Planned vaginal delivery reduces the risk of neonatal respiratory problems.Its incidence is 2-3% for VBAC as against 3-4%for elective CS.Elective repeat caesarian section[ERCS] increases the risk of future pregnancies and serious morbidity increases with the increasing number of CS .There is increased risk of placenta previa [10% after four CS].thromboembolism,wound infections with ERCS.Planned vaginal delivery require a shorter hospital stay and early recovery compared with ERCS.

b] Patient should be told about the risks associated with planned vaginal delivery viz. 1% increase in endometritis and 1% increase need for the blood transfusion.In an event of emergency CS ,there is increased maternal morbidity compared to ERCS.
There is increased risk of uterine rupture 22-74/10000 with VBAC.This risk is more if the labour is induced or augmented;more so if prostaglandins are used for induction of labour.
The patient needs to be informed that 2-3/10000 additional risk of birth related perinatal death compared with planned CS.The absolute risk of such birth related perinatal loss is comparable to the risk for the women having their first birth.
There is also increased risk of antepartum stillbirths after 39weeks in women with previous CS 10/10000 & overall increase in perinatal mortality at term.
Planned VBAC carries 8/10000 risk of infant developing HIE[hypoxic ischaemic encephalopathy] which may have long term development implications.
Patient has more chance of urinary,flatus/bowel incontinence following Vaginal delivery than CS.Written information should be given regarding the above risks.Patient wishes should be taken into account and further appointment dates given.

c] Patient is undelivered at 40 weeks,then she has options of conservative Mx,Induction of labour or planned elective CS.
She should be advised that at 40 weeks she can have vaginal examination and membranes sweeping and stretching;which may induce labour with in 48 hours.
In case she doesn\'t go in labour then she should be advised induction of labour[IOL] at 41 weeks.IOL at 41 weeks reduces the perinatal mortality and morbidity associated with post term pregnancy.Regarding IOL syntocinon infusion and amniotomy is betterfor her than use of prostaglandins;whioch has higher scar dehiscence rate.
In case the women refuses IOL then she should be monitored biweekly with CTG and deepest pocket of liquor measurement as per NICe guidelines.These measure do not decrease the incidence of adverse outcome which should be explained in written.
If the women reaches 42 weeks then the chnaces of adverse outcome increase ,so she should be offered Elective CS.Her wishes are taken into account and properly documented.
Posted by S M.
SM reply.
a)
Vaginal birth after cesarean (VBAC) has the advantage that it is a natural birth . VBAC avoids the risks of surgery .The woman can be discharged earlier from the hospital than after a cesarean.The pain experienced after birth is lesser after VBAC.The baby has lesser risk of developing Transient tachypnoea of the newborn and respiratory distress syndrome .The risk to the woman for future pregnancies are lesser after VBAC.
b)
Risk of planned vaginal delivery ( VBAC) is that it carries a 25 % risk of emergency cesarean section.As this woman has had no vaginal deliveries previously , this is a significant risk for her.which increases with induced /augmented labours. The risk of uterine scar rupture is upto 0.5 %, Further increase( 2-3 times) in this risk will occur in induced /augmented labours .The risks of maternal and perinatal mortality increase with uterine scar rupture.Risks of neonatal death or brain damage would be 0.2%.The woman also has 1% increased risk of requiring blood transfusion due to hemorrhage .The woman also carries a higher risk of endometritis after VBAC compared to planned cesarean section.
c)
At 40 weeks gestation, I would reconfirm the expected due date ( EDD) from dating scan. I will also confirm that there are no contraindications for VBAC. I will assess the mother\'s wishes for mode of delivery. If mother and fetus are well , I would like to offer to wait for one more week . Alternatively , she can have an elective repeat cesarean section.I would explain the pros and cons of these options. If at 41 weeks , she is still undelivered , I would offer induction of labour after explaining that the chances of successful VBAC are reduced from 75 % to 60 % with induced labours .Spontaneous labours are favourable for a successful VBAC.I will explain the need for an emergency cesarean section if fetal compromise or slow labour is detected.I will ensure that she is given writen information to back the counselling and that she has the required telephone numbers for use in an emergency . I will enquire if she has any further queries. I will offer to arrange a discussion with the consultant for the mode of delivery.
Posted by Arun J.
a- I would tell her that successful planned vaginal birth after cesarian section(CS) is associated with less morbidity, early recovery,and early return to work and no serious longterm risks for subsequent pregnancies such as placenta previa, accreta or subfertility associated with elective repeat CS(ERCS).

b- I would tell her that planned vaginal birth after CS(VBAC) if successful is associated with good outcome both for the mother and the baby.The risks for the mother include rupture uterus (22-74/10,000 VBAC),1% additional risk of blood transfusion,and infectious morbiditysuch as endometritis and effects on pelvic floor such as damage to the sphincters.I would brief her upo the risks to the fetus such as 2-3/10,000 additional risk of perinatal death,8/10,000 risk of hypoxic ischaemic encephalopathy, and antepartum stillbirth. I would also tell her that there is no significant difference in the rates of hysterectomy,maternal mortality,and thromboembolism between the two options.I would provide her with written information.I would also say her that preterm VBAC is associated with similar success as for term gestation,similar perinatal outcomes but more chance of thromboembolism,blood transfusion and coagulopathy .

c-There would be considerable anxiety in that she has not got into labour.So i would cousel her with atmost sensitivity.So first i would assess her to ascertain her chances of successful VBAC. This includes history(to find the indication of the previous CS,any complications like wound extension,genital sepsis,blood transfusion, interdelivery interval and a quick review of records to ascertain the type of CS, layer closure)then examination (to asses her BMI,pelvic examination to asses pelvic adequacy and cephalopelvic disproportion) and investigation( such as ultrasound to ascertain estimated fetal weight,presentation,sex of the fetus,placental position and fetal welbeing).I would tell her that success of VBAC depends on factors such as spontaneous onset of labour,rather than induction which is asssociated with rupture uterus(for oxytocin -7/1000,& PGE2- 25/1000 inductions), size of the fetus( no macrosomia) and cephalic presentation,normal BMI with adequate pelvis and interdelivery interval of > 18 months. Anaesthetic and paediatric review arranged . I would tell her that membrane sweep is an option for induction of labour with less morbidity to her.She needs consultant led care with immediate access to emergency CS,electronic fetal heart monitoring and partogram during labour.Epidural analgesia is used for pain relief.Early recourse to CS if any abnormality(secondary arrest,prolonged variable decelerations in CTG etc)is noticed.Episiotomy would be given and second stage helped out with outlet forceps.Iwould give her written information.
Posted by Osman A.
a) Planned Vaginal delivery after cesarean section (VBAC) is associated with lower risk of respiratory morbidity to the neonate. It is associated with lower risk of placenta previa and accreta. Planned VBAC avoid the risk of repeat CS like adhesion and visceral injury. It is also reduce the risk of VTE (venous thromboembolism). Written information should be given to her.
b. VBAC is associated with increased risk of scar rupture (22-74/10,000). It is also associated with 1% risk of blood transfusion. Risk of endometritis is also reported to be 1%. Addition of 2-3/10,000 risk of birth related perinatal death in VBAC. Risk of HIE (Hypoxic Ischemic encephalopathy) is increased (8/10,000) in neonate who delivered by VBAC. Planned VBAC carries risk of 10/10,000 antepartum stillbirth after 39 weeks. Written information should be given about VBAC.
c. She should be counselled that induction of labour (IOL) in the presence of previous scar double or triple the risk of scar ruptured. It is also increased 1.5 fold of CS. The women should be made to understand that she should be delivered if her pregnancy progress to 42 weeks as it is associated with risk of stillbirth. Post date also associated with increase risk of meconium aspiration and dystocia. IOL and pregnancy >41 weeks increases the risk of failed IOL. She should be advised to go for close monitoring (CTG, weekly Doppler and amniotic fluid index) until spontaneous labour occur. But these kinds of monitoring value in predicting fetal demise are unknown. If her labour is induced or achieve spontaneous labour, the CTG should be monitored continuously. Intravenous line should be secured and cross match should be sent. Her progress of labour should be assessed regularly according to partogram, prolonged labor should be avoided. Use of oxytocine is not contraindicated, but it should be used carefully. Sign and symptoms of scar ruptured should be checked. Ultimately, risk of repeat CS and risk of scar ruptured if labour is induced should be explained to the patient. Written information should be given.
Posted by Kp K.
I would tell her that the planned vaginal delivery has a 72-76% of success rate. There will be less morbidity as compared to caesarean section as fast recovery , no scar on the abdomen , less incidence of infection, blood loss and of deep vein thrombosis . Baby will have less incidence of respiratory distress in vaginal delivery. Increase chance of vaginal delivery in subsequent pregnancy if had successful VBAC.

The risk of uterine rupture of around 22-74/1000 this would necessitate emergency laparotomy , increase blood loss , neonatal morbidity and mortality and possibility of hysterectomy. 1% risk of endometritis and blood transfusion in vaginal delivery. Increase in hypoxic ischaemic encephalopathy and birth related perinatal death as compared to caesarean section. Continuous fetal and maternal monitoring in labour that will restrict her mobility.



Aim of counselling would be to give her pros and cons of spontaneous labour, induction of labour and caesarean section at this stage which will help her to make an informed choice and to support her decision. She should be informed that delivery would be conducted in a well equipped delivery unit with one to one care , facilities for continous electronic monitoring, threatre , anaesthetist , blood bank and haematologist.
As she opted for the vaginal delivery she should be informed that the chances of successful VBAC would increase if she goes in spontaneous labour as compared to induction of labour. Membrane sweep can be offered if cervix favourable that will decrease her chances to go for induction. Decision for induction would be by the consultant obstetrician, between 41- 42 weeks. Induction with prostin carries 2-3 fold increase in uterine rupture as compared to syntocinon infusion. Syntocinon can be monitored well but a chance of failed induction is high fr poor bishop score. If previous caesarean was for dystocia, increase chance of failed induction. For pain relief epidural is not contraindicated. The method of induction would be decided by the consultant obstetrician and targeted progress to monitor would be planned and if not achieved would need caesarean section to prevent uterine rupture. If rupture uterus confirmed then blood transfusion with the possibility of hysterectomy and ITU admission is anticipated.


Patient should be given written information leaflets and time to discuss with the partner.
Her wishes should be fully supported.

Posted by Ron C.
A.
Benefits of VBAC (vaginal birth after caesarean) are mainly related to avoiding disadvantages of another caesarean if successful. Recovery will be faster with less maternal morbidity (thrombosis, haemorrhage, visceral injury), making it easier to cope with the newborn and the (young) child she has already. Breastfeeding is more likely to be successful, improving bonding. On average neonatal respiratory problems will be less. As a 2nd caesarean means any subsequent delivery should be by means of caesarean, women keen for a large family would benefit form VBAC. Benefits of elective caesarean are mainly related to avoiding increased risks of a VBAC for mother and baby.

B.
VBAC may not be successful, partially depending on the indication for the previous caesarean. It may also lead to scar rupture in 1:200 attempts. In these situations an emergency caesarean is arranged, which in itself is related to higher maternal morbidity, such as obstetric haemorrhage, which may require a caesarean hysterectomy. Additional perinatal mortality is 1-3:1000, about similar to 1st time deliveries, and neonatal morbidity requiring admission to the neonatal unit is higher. These number approximately double if labour is induced.

C. I will tell her she should ideally be delivered before 41 weeks as incidence of IUD and perinatal morbidity will rise progressively after this time. As induction would double the risks for scar rupture and associated morbidity, it is not recommended. If spontaneous onset of labour occurs before 41 weeks we can still pursue a VBAC, and to improve this likelihood I’ll offer stretch and sweep, if needed to be repeated in 3 days if no effect. If by 41 weeks still not delivered and patient keen, amniotomy can be done if the cervix is favourable. This may lead to spontaneous contractions, but if not, use of oxytocin for induction is not recommended, again for increased risk of scar rupture. If not successful or patient not keen, an elective caesarean will be done at 41 weeks. I’ll provide the couple with written information and contact number if contractions develop.
Posted by J P.
J wrote
a.All women with previous one low transverse caessarean and now uneventful pregnancy should be offered VBAC and discussed the risks and benefits.VBAC has a success rate of 72-76%.Maternal benefits like risks due to major surgery like haemorrhage ,thromboembolism and anaesthetic complications are avoided.Long term risks for future pregnancy due to ERCS like adherent placenta,repeat caessarean,need for transfusions,hysterectomy if complications arise are avoided.Incidence of tranient tachypnea of new born and respiratory distress syndrome are decreased when compared to ERCS.

b.Planned VBAC has increase in incidence of endometritis and blood transfusion compared to ERCS.Risk osf scar dehiscence is 0.5% and uterine rupture occurs at a rate of 22-74/10000 cases which is more in labour if it is induced or augmented.Complications in VBAC are mainly due to failed ones and are uterine rupture,blood transfusion,hysterectomy,long stay in hospital.Mortality dur to uterine rupture in VBAC is very rare and occurs at 1/100000 cases.Perinatal deaths are increased and the incidence of hypoxic ischaemic encephalopathy are increased in VBAC.

c.Since she remains undelivered at 40 weeks she will be informed of the fetal risks like increased perinatal morbidity and mortality,meconium staining of liquor ,increase in need of emergency caessarean section if she remains undeliverd by 42 weeks.Optimum management may be formal sweeping of membranes after pelvic assessment.Repeat assessment may be given at the next appointment by 41 weeks.Time limit for expextant management will be formed.I will inform her VBAC may fail in 25 % of cases ,more so in induced labours and also the risk of uterine rupture is incresed three to five fold in induced labours.The risk of rupture is more with prostaglandins than oxytocin alone but oxytocin may fail in unfavourable cervix.Usually single dose of prostaglandin used and repeated doses avoided.
The decision to induce or augment ,timing of intervals for vaginal examination,stop augmentation will be decided by the consultant.Pelic examination should be done by the same person at fixed intervals.Labour should be in hospital with necessary facilities for emergency caessarean section.Continuous elctronic monitoring will be done.Epidural analgesia will be provided if opted.Oxytocin augmentation will be done carefully to attain 3-4 contractions in 10 min.Written information and full documentation of the discussion will be made.

Posted by Archna M.
a)I will like the women to know that the advantages of successful planned VBAC(vaginal birth after C.S.) over ERCS (elective repeat C.S.) are decreased post operative morbidity ,shorter hospital stay, decreased risk of infective morbidity. In future pregnancy chances of repeat C.S. are higher if she has ERCS in current pregnancy, leading to significantly increased risk of placenta previa, placenta accreta, massive hemorrhage & blood transfusion, hysterectomy, endometritis, scar dehiscence and risk of bladder & bowel injury. Regarding the neonate she should know that neonatal respiratory morbidity in the form of respiratory distress syndrome and transient tachypnea of new born are higher in ERCS group as compared to VBAC(3-4% vs 2-3%).

b) In planned VBAC there is never a guarantee of successful vaginal birth thus risk of failed VBAC and Emergency C.S. are always there which has higher complication rates as compared to ERCS. In VBAC risk of rupture uterus or scar dehiscence if almost .2-.7% while in ERCS it is practically zero. There is 1% additional risk of blood transfusion and endometritis in planned VBAC .There is additional risk of birth related perinatal mortality (2-3/10,000) in VBAC and it is comparable to women who deliver for the first time. This risk is more so due to increased risk of IUD with increasing gestation and especially after 39 wks. and can be prevented with planned CS at 39 completed wks. There is 8/10,000 risk of HIE in VBAC, long term sequel is not yet known. It is mostly due to rupture uterus.

c)First of all I will confirm her gestational age with 1st trimester ultrasound scan report so that chances of early and unnecessary intervention can be avoided. I will tell her that with increasing gestation risk to the fetus and neonate increases in terms of unexplained IUD, meconium aspiration, increased perinatal mobidity & mortality and to mother increased risk of C.S. or operative delivery is there thus it is preferable that she delivers by 42 wks. of gestation. Decision has already been taken for Planned VBAC but as she has not delivered yet so I will like to counsel her again explaining pros and cons of VBAC & ERCS with evidence based facts. She should know that risk of failed VBAC are higher in induced or augmented labour , also in case of BMI >30,previous C.S. for dystocia or expected fetal macrosomia in current pregnancy. I will rule out multiple pregnancy, breech or other non-vertex presentation, placenta previa where ERCS may be mandatory or careful decision is warranted. After ruling out any contraindication to vaginal birth, confirming fetal well being and after re-counseling If decision is taken for VBAC then I will tell her that she can wait for spontaneous labour pains till 41+3 wks. She will be reassessed then for fetal status by examination, ultrasound and CTG. Vaginal examination will be done for bishop scoring and sweeping which some women can find uncomfortable but it has been seen to help in inducing labour. Further induction can be done with vaginal prostaglandins or oxytocin. Risk of rupture uterus is higher with prostaglandin use . The decision for induction will be taken by consultant .Induction should be done in delivery suit which is well staffed with facilities for continuous fetal monitoring ,well trained staff, facility for emergency C.S. and advanced neonatalal care. She can be given epidural analgesia. Risk of failed VBAC are higher in women without epidural. All preparations will be ready for provisional C.S. for emergency. In case CTG shows any sign of scar dehiscence or rupture, she will immediately be taken for emergency C.S. She should be explained well about all this ,information leaflets be given and proper clear documentation of plan of management and discussion should be done on her hand held notes.
Posted by Ava L.
a- Planned VD is associated with less incidence of placental implantation complication in future pregnancies like placenta praevia and placenta accrete in comparison to caesarean section. Also it is not associated with risk of surgery like visceral injury, adhesion formation or risk of anaesthesia. Moreover if she deliver vaginally, she will be more likely to have successful VDs in future.

b- On the other hand, I will inform her that vaginal delivery carries increased risk of scar dehiscence during labour, it occurs in 3-7 per 1000 patients, while PRCS didn\'t have that risk. In addition VD associated with increased risk of perineal trauma, perineal tears and future genital prolapse. Stress incontinence and occult anal sphincter injury can also result from VD. Also the is increased incidence of fetal distress, fetal hypoxic ischemic encephalopathy ( around 1 in 800 live birth) and increased perinatal morbidity and mortality. If planned vaginal delivery fail, the woman will have emergency CS which carries more risk than planned elective CS.

c- I will inform her that pregnancy beyond 40 weeks will be associated with increased risk of perinatal morbidity and mortality. Management options are explained to her. These can be expectant management , induction of labour or elective planned repeated CS. Expectant treatment can be offered if both fetal and maternal conditions are reassuring. CTG is done twice per week. She has a chance of starting spontaneous delivery within one week duration. The woman is advised to report early if she feel reduction in fetal movements or if she has abdominal pain or signs of labour. Spontaneous labour is associated with increase chance of having successful VD. She will need USS to assess amount of liquor. We advice her that she preferably not progress beyond 41 weeks gestation. Induction of labour can be offered also, it can be done via membrane sweeping and ARM. We tell her that she will required continuous EFM. Oxytocin is not absolutely contraindicated, but its\' usage should be with extreme precaution to adjust titer to avoid risk of rupture uterus. Regional anaesthesia is not contraindicated , however, it will be associated with increased risk of operative or instrumental delivery. We try to reassure her and that she will get one to one care, progress of her labour will be followed willalso We try to explore her wishes to have such trial of vaginal delivery, also her attitude if complications occur during labour. Written information is given. If she select to undergo planned ECS, her wishes should be respected. Clear documentation is done.
Posted by A S.
Dear Dr Paul
About epidural in VBAC it is written in the guideline

A number of factors are associated with successful VBAC. Previous vaginal birth, particularly
previous VBAC, is the single best predictor for successful VBAC and is associated with an
approximately 87–90% planned VBAC success rate.21–23 Risk factors for unsuccessful VBAC are:
induced labour, no previous vaginal birth, body mass index greater than 30,24–26 previous caesarean
section for dystocia.21 When all these factors are present, successful VBAC is achieved in only 40%
of cases.21 There are numerous other factors associated with a decreased likelihood of planned
VBAC success:21,22,27–30 VBAC at or after 41 weeks of gestation, birth weight greater than 4000 g;
no epidural anaesthesia, previous preterm caesarean birth, cervical dilatation at admission less than
4 cm, less than 2 years from previous caesarean birth, advanced maternal age, non-white ethnicity,
short stature and a male infant. Where relevant to the woman’s circumstances, this information
should be shared during the antenatal counselling process to enable the woman to make the best
informed choice.
B




Evidence
level IV
Evidence
level IIa
Evidence
levels
IIa, IIb
3 of 17 RCOG Green-top Guideline No. 45
Evidence
level IIa,
IIb, III


About recovery after VBAC , in the patient information leaflet .issued september 2008 by RCOG

What are the advantages of a successful VBAC?
The advantages of a successful VBAC include:
● a vaginal birth (which might include an assisted birth)
● a greater chance of an uncomplicated normal birth in future pregnancies
● a shorter recovery and a shorter stay in hospital
● less abdominal pain after birth
● not having surgery.
Posted by A H.
a)I would tell her that she has a seventy-five percent chance of having a successful vaginal birth after caesarean section(VBAC). Benefits include less respiratory problems in the neonate, including both transient tachypnoea of the newborn and respiratory distress syndrome. She will have an increased chance of having a successful VBAC in subsequent pregnancies of around 90 percent. Also, subsequent pregnancies will be less complicated than if an elective repeat caesarean section(ERCS) is performed. Increasing numbers of caesarean sections are associated with increased risk of placenta praevia/ accreta, injury to viscera, hysterectomy, blood transfusions and admission to intensive care unit .

b)The risks associated with VBAC include uterine rupture of approximately 22- 74 percent. There is also an additional one percent risk of both endometritis and blood transfusion. Fetal risks include antepartum stillbirth while awaiting VBAC as well as birth related perinatal death. The risk of hypoxic ischaemic encephalopathy is also increased but its long term effect on the baby is not known.
Unsuccessful VBAC will necessitate an emergency repeat caesarean section which is associated with greater maternal morbidity than ERCS

c) She would be counseled on the risks and benefits of awaiting spontaneous onset of labour as opposed to induction of labour.
She would be advised that her baby has an increased risk of dying in utero if the pregnancy goes beyond forty three weeks. However fetal well-being will be monitored by twice weekly CTG. An emergency repeat caesarean section will be required if there are CTG abnormalities. This carries increased risks compared with ERCS. Her increased risks include visceral injury, haemorrhage and venous thromboembolism which can be fatal.
There is a reduced chance of having a successful VBAC after forty one weeks. She will be advised that induction of labour is an option but it is associated with a three fold increased risk of uterine rupture and a 1.5 -fold increased risk of caesarean section.
The risk of rupture is higher if prostaglandins are used compared with oxytocin. She will be advised of the need for serial assessment of the cervix to assess progress of labour. This may have to be performed more frequently so that poor progress can be identified in a timely manner to allow early recourse to caesarean section. She would be advised that there is no reliable method of detecting if uterine rupture is imminent, for example intrauterine pressure measurements.
Counseling for augmentation or induction of labour will ideally be done by the consultant or most senior obstetrician and recorded in the antenatal notes.
Posted by Atashi S.
a) I will tell her success rate of vaginal birth after cesarean section is about 70% to 76%. Vaginal birth associated with lesser incidence of neonatal respiratory distress syndrome (2 to 3% compared with 3to 4% in elective C/S). Incidence of Placenta previa and placenta acreta will reduce after successful planned vaginal delivery in her future pregnancy.
(b) Increase incidence of scar dehiscence or rupture .The risk is 74 /10,000.There is an additional 1% risk of blood transfusion .VBAC is associated with increased risk of infection which may led to endometritis.
Antepartem still birth rate will increase after 39 weeks. Infant born with vaginal delivery is also at risk of developing hypoxic encephalopathy. Risk is 8/10,000. I will give her written information regarding benefits and risks of VBAC.
( c) I will provide her information regarding advantage and disadvantage of spontaneous labour , induction of labour and elective cesarean section. I will counsel to help her to make an informed choice and to support her decision. She should be informed that chance of vaginal delivery will increase if she goes to spontaneous labour compared to induction of labour. Induction of labour with prostaglandin will increase risk of scar rupture 2-3 fold. If cervix remains unfavourable I will do sweeping of the membrane.I will go for induction at 41-42 weeks but another option in expected management upto 42 weeks according to opinion of her. I will provide her written information.

Posted by Ashwinibilagi25 B.
(a) What would you tell her about the benefits of planned vaginal delivery compared to planned caesarean section? [3 marks]

Quicker recovery after delivery reduced hospital stay . the babies born normally tend to have lesser respiratory problems (2-3 %) than by cesarean section (3-4%). It would keep the option of vaginal delivery safer for the subsequent deliveries and future risks of placenta accreta, increased hospital say, ICU admission, injury to bladder, bowel and blood vessels be reduced.

b) What would you tell her about the risks of planned vaginal delivery compared to planned caesarean section? [7 marks]
The risks of planned vaginal delivery would be- risk of scar rupture ( 26-72/10,000) –she would be monitored continuously in labor to identify and manage if it happens, the signs would be abnormal cardiotocography,continuous abdominal pain, scar tenderness, haematuria, bleeding, maternal tachycardia, hypotension, shortness of birth shoulder pain and this would need an emergency Ceserean section
Risk of blood transfusion and endometritis (1 %) the blood transfusion risk is present in both the ways , and he risk of endometritis can be reduced by giving antibiotic if she is at high risk of infection and making sure the placenta is complete on delivery
Risk of hypoxic ischemic encephalopathy (8%) this could be easily avoided by close monitoring of the CTG ,involving the senior members of team ( consultants ) and by having a comprehensive plan regarding the augmentation of labor and parameters to resort to Ceserean section
Risk of Perinatal mortality (3/10,000) deliveries this risk though very serious is maniacal in its frequency ,again could be prevented by good team work and involvement of senior members of the team
The risk of Ceserean sections are-- Incidence of placenta accreta in future pregnancies, Increased operating and recovery time, risk of blood transfusion, infection ,admission to ICU ,injury to bowel, blood vessels and ureters , thromboembolism ,cut on the baby (2%)

c) She opts for planned vaginal delivery but remains undelivered at 40 weeks gestation. How would you counsel her? [10 marks]
I would talk to patient and see what her preferences are.She can either wait for another week with cervical sweeps to be induces or decide to have a elective ceserean sections.
I would tell her that there is a 2-3 fold increase in the incidence in uterine rupture (2-3 times 22-62/10000) and 1.5 times the chances of Ceserean section compared to spontaneous labourers.
Induction by prostaglandins has even more risks of scar rupture.
If patient is keen to go ahead with induction I would tell her that I would involve my consultant in deciding the method of induction ,time intervals between cervical assessments,when to augment and to decide the parameters when to decide for cessation of induction and taking for section
If she decides to go for a ceserean section I wiould book a date for elective ceserean section with in next 10 days time ,if she decides to go for induction I would ask her book an appointment with her midwife for another cervical sweep,and if that doesn’t put her in to labor,we might have to induce her and I will give her a date for induction.
I will make sure she understands the implications and allow her to make an informed decision will inform her it is a important decision for her and give her the 24 hour labor ward number to contact us if she needs to discuss about the options again