VBAC and Uterine Scar Dehiscence Alwayn Leacock Staff Grade 15/10/08

Profile Mrs. C.V. 34 YO Gr2 p 1 Rhesus +ve Gest: T + 4

Current pregnancy LMP 27/08/07 EDD 5/06/08 Uneventful antenatal care At 36/40 discussed and agreed to VBAC in ANC Attended ANC @ T+², VE cervix 1.5 cm long and tightly closed ELSCS booked for 10/06 if labour was not spontaneous

Past Obstetric History 2006 EmLSCS at Royal Berks in Reading For failure to progress in labour and Foetal distress A 3800gms female was delivered .

Confinement 0800 hrs 9/6/08 Self referral to CDS Contracting since 0530hrs Midwife VE at 0815 hrs - 4cm dilated - Cephalic - Occiput posterior station 0-³ - Bulging membranes felt *

Management 0830 hrs IV canula sited Bloods taken for - 1. Group and save 2. FBC 0930 hrs oral Ranitidine given 0955 hrs Pethidine given IM

Progress of labour 1040 hrs she complained of scar being sore i.e. A burning sensation being present all the time 1100 hrs Vaginal Examination - 6cm dilated ? OP - Station 0-² - Membranes intact * - Contracting 4:10

1130hrs Registrar review - CTG was reassuring - Abdomen soft, non tender, no scar tenderness elicited - No bleeding PV- no concern about uterine rupture - ARM requested at the next step - Encouraged to consider an epidural

Progress in labour 1150hrs Some Shallow decelerations, occasionally late mostly early Draining pink liquor ? Hind water rupture Complained of increased rectal pressure Registrar informed re: shallow decelerations

Contd: 1215 hrs - variability > 5bpm - no decelerations - contracting 4:10 1245 hrs - late decelerations - variability <5bpm - Good recovery

Contd: 1254hrs difficulty voiding on bedpan - encouraged to walk to toilet 1315hrs still had not voided Midwife VE draining old meconeum liquor 9cm dilated Vx 0-² OT

Labour contd: 1340 hrs consultant review Review in 1 hour if not fully dilated to have epidural, Big baby suspected IVI please 1345 hrs started involuntarily pushing 1400 hrs FSE applied

Registrar review 1530hrs - Falling baseline on CTG Rate 140 Good variability Variable to late decelerations VE OA caput ++ moulding + station O instructed to commence pushing 1604 hrs reviewed after pushing for one hour and not delivered transferred to theatre for EUA and trial of instrumental delivery

In Theatre Spinal inserted When the patient was laid recumbent following the insertion of the spinal anaesthetic a saddle shaped camel hump abdomen was noted that was not evident prior to going to theatre Proceeded direct to LSCS

Findings at LSCS Thick meconeum in the abdomen Large haematoma at the right uterine angle Right shoulder and arm in the maternal abdomen live male delivered weighing 4220gms Almost bloodless field <300mls lost Ph A7.06 V 7.11

Post op Day 3 developed fever and abdominal bloating UTI excluded ? Wound sepsis Antibiotics commenced ? Ileitis ? peritonitis due to meconeum Mother and baby discharged day 7

Risk factors for uterine rupture Low transverse caesarean section Classical caesarean sections Myomectomy Twins/ multiple birth Transverse lie More than five pregnancies Prostaglandins Cytotec (misoprostol)* Any uterine surgery/MROP Any instrumental delivery

Incidence of uterine rupture 1:625 with one previous section 1:192 for VBAC women in spontaneous labour 1:129 if induced with non prostaglandin agent 1:49 if prostaglandins are used 1] Vause and Macintosh Use of prostaglandins to induce labour in women with a caesarean section scar BMJ 1999;318:1056-1058 ( 17 April

Background risk maternal death Morbidity/mortality If the uterus ruptures 1:18 babies died 1:23 women required hysterectomy Background risk maternal death 1:3500 if no prostaglandins were used 1:11000 if elective LSCS New England Journal of Medicine (July 5, 2001, v345, pages 3-8),

Pros for VBAC Easier recovery than caesarean. Satisfaction of achieving vaginal delivery. Sense of undoing prior negative experience. Slightly safer for mother and baby in most cases. Knowledge that at least you tried, even if caesarean is ultimately needed. .

Cons against VBAC Rare major complication of uterine rupture, which can lead to emergency surgery, possible blood transfusions for mother or baby, possible hysterectomy, and even death of the baby or mother. Greater risk of uterine infection for mothers who have laboured and then have a caesarean. Risk of repeating prior negative experience if caesarean becomes necessary. Risk of need for emergency caesarean, which is more frightening than a scheduled caesarean and has a somewhat greater risk of complications

Counselling and consent Anecdotal evidence that at GWH patients are given the leaflet about VBAC and sent away and not counselled about the risks vis-à-vis possibility of uterine rupture, severe PPH, DIC, Hysterectomy Given the potential for devastating consequences. Should all women who agree to VBAC be asked for written consent.?

Where do we go from here? There have been five recorded cases of uterine rupture since encountering my first in November 2007. this include one twin pregnancy left for C/S at 39/40 A prospective audit is required for all women with previous caesareans who have a repeat caesarean section looking specifically at scar integrity This may show the need to offer earlier caesareans or all women with previous scar a caesarean and not VBAC

References BMJ  2004;329:375 (14 August), doi:10.1136/bmj.38160.634352.55 (published 19 July 2004) Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study BMJ Jul 2004; 329: 19; doi:10.1136/bmj.329.7456.19 incidence and consequences of uterine rupture in women with previous caesarean section...incidence and consequences of uterine rupture in women who have had a delivery by caesarean BMJ Feb 2003; 326: 0g; doi:10.1136/bmj.326.7384.0/g Synopsis...comparing the rate of diagnosis of uterine rupture in women with and without prior caesarean...... Am J Obstet Gynecol. 1991 Oct;165(4 Pt 1):996-1001. Links Uterine rupture during trial of labor after previous caesarean section.

Caveat lector Listen to the patient Examine the abdomen Examine the abdomen again Epidurals may mask clinical presentation and give a false sense of security CTG may positively falsely reassure doctors, midwives and patients Have a very low threshold for LSCS