The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

RISKRISKCLINICAL

The AVMA Medical and Legal Journal

Incorporating

Healthcare & Law Digest

VAGINAL BIRTH AFTER VAGINAL BIRTH AFTER CAESAREAN SECTIONCAESAREAN SECTION

Alternative: Trial of ScarAlternative: Trial of Scar

or Trial of Vaginal Deliveryor Trial of Vaginal Delivery

Not Not Trial of LabourTrial of Labour

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Roger V ClementsEditor:Clinical Risk

V B A CV B A C Risk of RuptureRisk of Rupture

(Meta Analysis - Dickinson)(Meta Analysis - Dickinson)

Enkin (1989) 4153 0.8%Enkin (1989) 4153 0.8%

Miller (1994) 10880 0.6%Miller (1994) 10880 0.6%

Flamm (1994) 5022 0.8%Flamm (1994) 5022 0.8%

McMahon (1996) 3249 0.3% McMahon (1996) 3249 0.3%

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(Meta Analysis - Clements)(Meta Analysis - Clements)

Rosen (1991) >6000 c2%Rosen (1991) >6000 c2%

Scott (1991) 196 1.5%Scott (1991) 196 1.5%

ACOG (1994) ? 2.0% ACOG (1994) ? 2.0%

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VAGINAL BIRTH AFTER VAGINAL BIRTH AFTER CAESAREAN SECTIONCAESAREAN SECTIONRisks of Caesarean sectionRisks of Caesarean section

Maternal Mortality of Maternal Mortality of

ElectiveElective Caesarean Section is of Caesarean Section is of the order of 1 in 10,000the order of 1 in 10,000

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Is there a duty to warn?Is there a duty to warn?

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““I am not aware of any credible I am not aware of any credible VBAC study that did not report VBAC study that did not report

adverse outcomes….adverse outcomes….Gleicher N (1991) Letter. Obstetrics & Gleicher N (1991) Letter. Obstetrics &

Gynaecology 78.4.727Gynaecology 78.4.727

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““Nor am I aware of any VBAC Nor am I aware of any VBAC proponent who would not advise proponent who would not advise

patients of the risk of rupture patients of the risk of rupture during labor…...during labor…...

Gleicher N (1991) Letter. Obstetrics & Gleicher N (1991) Letter. Obstetrics & Gynaecology 78.4.727Gynaecology 78.4.727

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““The question is not whether The question is not whether uterine rupture occurs; we know uterine rupture occurs; we know

it does….it does….Gleicher N (1991) Letter. Obstetrics & Gleicher N (1991) Letter. Obstetrics &


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““The real question is, what The real question is, what incidence of adverse outcome are incidence of adverse outcome are

we willing to accept?”we willing to accept?”Gleicher N (1991) Letter. Obstetrics & Gleicher N (1991) Letter. Obstetrics &


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““Scott makes a valid point in Scott makes a valid point in stating that rupture rates are stating that rupture rates are

underreported…….underreported…….Gleicher N (1991) Letter. Obstetrics & Gleicher N (1991) Letter. Obstetrics &


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““However, the question should be not only However, the question should be not only what are reported rates of rupture but what are reported rates of rupture but what is an acceptable rate of rupture what is an acceptable rate of rupture

within a particular institution”within a particular institution”

Gleicher N (1991) Letter. Obstetrics & Gleicher N (1991) Letter. Obstetrics & Gynaecology 78.4.727Gynaecology 78.4.727

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““The bottom line is that neither The bottom line is that neither VBAC nor it(s) alternative are VBAC nor it(s) alternative are

risk free…..the best solution is to risk free…..the best solution is to make it safer...make it safer...

Flamm B.L. Vaginal birth after cesarean: where have we been and Flamm B.L. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53 11 where are we going? Obstetrical and Gynecological Survey 53 11

661-662 1998661-662 1998

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““A large study of uterine rupture A large study of uterine rupture found that all infants did well found that all infants did well if if

delivered within 17 minutes of the delivered within 17 minutes of the onset of a prolonged deceleration.onset of a prolonged deceleration.

Flamm B.L. Vaginal birth after cesarean: where have we been and Flamm B.L. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53 11 where are we going? Obstetrical and Gynecological Survey 53 11

661-662 1998661-662 1998

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““But the main risk of VBAC is But the main risk of VBAC is uterine rupture. This occurs in 1 uterine rupture. This occurs in 1

percent of patients. percent of patients. Phelan J.P. Vaginal birth after cesarean: where have we been and Phelan J.P. Vaginal birth after cesarean: where have we been and

where are we going? Obstetrical and Gynecological Survey 53. 11 where are we going? Obstetrical and Gynecological Survey 53. 11

662-663 1998662-663 1998

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““Moreover, the risk is in addition to Moreover, the risk is in addition to the usual risks associated with a the usual risks associated with a

trial of labor in patients without a trial of labor in patients without a uterine scar…….uterine scar…….

Phelan J.P. Vaginal birth after cesarean: where have we been and Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53. 11 where are we going? Obstetrical and Gynecological Survey 53. 11

662-663 1998662-663 1998

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““I understand that if my uterus ruptures I understand that if my uterus ruptures during my VBAC, there may not be during my VBAC, there may not be

sufficient time to operate and to prevent sufficient time to operate and to prevent the death of or permanent brain injury to the death of or permanent brain injury to

my baby”my baby” Phelan J.P. Vaginal birth after cesarean: where have we been and Phelan J.P. Vaginal birth after cesarean: where have we been and

where are we going? Obstetrical and Gynecological Survey 53. 11 where are we going? Obstetrical and Gynecological Survey 53. 11

662-663 1998662-663 1998

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V B A CV B A CWhat the Textbooks RecommendWhat the Textbooks Recommend

EligibilityEligibility• 1 previous lscs - no other adverse features1 previous lscs - no other adverse features

• Twins, breech & non diabetic macrosomiaTwins, breech & non diabetic macrosomia

• More than one previous lscs is controversialMore than one previous lscs is controversial

• Patient preference may influence choicePatient preference may influence choice

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EligibilityEligibility

Generally accepted contraindications Generally accepted contraindications include:include:

• previous classical caesarean sectionprevious classical caesarean section

• diabetic macrosomic fetusdiabetic macrosomic fetus

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ConductConduct• Critical review of progress of labourCritical review of progress of labour

• Continuous fetal heart rate monitoringContinuous fetal heart rate monitoring

• The issues of intravenous access and cross-The issues of intravenous access and cross-matching of blood are more controversialmatching of blood are more controversial

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ConductConduct• Prostaglandins may be used - not any more!Prostaglandins may be used - not any more!

• Caution should be exercised with oxytocinCaution should be exercised with oxytocin

• Regional analgesia not contraindicatedRegional analgesia not contraindicated

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V B A CV B A CWhat the Literature saysWhat the Literature says

Prostaglandins Prostaglandins

““For women with one prior cesarean delivery, the risk of uterine rupture is higher among those whose labor is induced than amongst those with repeated cesarean delivery without labor. Labor induced with prostaglandins . Labor induced with prostaglandins confers the highest risk”confers the highest risk”

Lydon-Rochelle et al ‘Risk of uterine rupture during labor among women with a Lydon-Rochelle et al ‘Risk of uterine rupture during labor among women with a prior cesarean delivery’ N Eng J Med Vol 343:1:3-8 July5th 2001prior cesarean delivery’ N Eng J Med Vol 343:1:3-8 July5th 2001

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V B A CV B A C

Personal SeriesPersonal Series

31 following LSCS31 following LSCS

1 followed myomectomy1 followed myomectomy

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V B A CV B A CPersonal SeriesPersonal Series

31 after LSCS31 after LSCS

In only three case did there In only three case did there appear to me to be no appear to me to be no

breach of dutybreach of duty

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31 after LSCS31 after LSCS9 mothers were injured9 mothers were injured

27 babies were either injured 27 babies were either injured or diedor died

In 5 cases both mother and In 5 cases both mother and baby were injuredbaby were injured

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9 Maternal Injuries9 Maternal Injuries2 Hysterectomies (one with brain 2 Hysterectomies (one with brain damage following prolonged shock)damage following prolonged shock)

1 Delayed hysterectomy (accreta)1 Delayed hysterectomy (accreta)

5 Bladder Injuries (including two 5 Bladder Injuries (including two vesico-vaginal fistulae)vesico-vaginal fistulae)

1 Psychiatric (following delayed 1 Psychiatric (following delayed recognition)recognition)

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27 Fetal Injuries27 Fetal Injuries4 Stillbirths4 Stillbirths

9 Neonatal Deaths9 Neonatal Deaths

14 Survivors with Cerebral Palsy14 Survivors with Cerebral Palsy

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RISKRISKCLINICAL

The AVMA Medical and Legal Journal

Incorporating

Healthcare & Law Digest

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The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest