The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

VAGINAL BIRTH AFTER CAESAREAN SECTION Alternative: Trial of Scar or Trial of Vaginal Delivery Not Trial of Labour RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture (Meta Analysis - Dickinson) Enkin (1989) % Miller (1994) % Flamm (1994) % McMahon (1996) % RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture (Meta Analysis - Clements) Rosen (1991) >6000 c2% Scott (1991) % ACOG (1994) ? 2.0% RISK CLINICAL Roger V Clements Editor:Clinical Risk

VAGINAL BIRTH AFTER CAESAREAN SECTION Risks of Caesarean section Maternal Mortality of Elective Caesarean Section is of the order of 1 in 10,000 RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture Is there a duty to warn? RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “I am not aware of any credible VBAC study that did not report adverse outcomes…. Gleicher N (1991) Letter. Obstetrics & Gynaecology RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “Nor am I aware of any VBAC proponent who would not advise patients of the risk of rupture during labor…... Gleicher N (1991) Letter. Obstetrics & Gynaecology RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “The question is not whether uterine rupture occurs; we know it does…. Gleicher N (1991) Letter. Obstetrics & Gynaecology RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “The real question is, what incidence of adverse outcome are we willing to accept?” Gleicher N (1991) Letter. Obstetrics & Gynaecology RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “Scott makes a valid point in stating that rupture rates are underreported……. Gleicher N (1991) Letter. Obstetrics & Gynaecology RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “However, the question should be not only what are reported rates of rupture but what is an acceptable rate of rupture within a particular institution” Gleicher N (1991) Letter. Obstetrics & Gynaecology RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “The bottom line is that neither VBAC nor it(s) alternative are risk free…..the best solution is to make it safer... Flamm B.L. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “A large study of uterine rupture found that all infants did well if delivered within 17 minutes of the onset of a prolonged deceleration. Flamm B.L. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “But the main risk of VBAC is uterine rupture. This occurs in 1 percent of patients. Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “Moreover, the risk is in addition to the usual risks associated with a trial of labor in patients without a uterine scar……. Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Risk of Rupture Risk of Rupture “I understand that if my uterus ruptures during my VBAC, there may not be sufficient time to operate and to prevent the death of or permanent brain injury to my baby” Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C What the Textbooks Recommend Eligibility Eligibility 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 choiceRISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C What the Textbooks Recommend Eligibility Eligibility Generally accepted contraindications include: previous classical caesarean sectionprevious classical caesarean section diabetic macrosomic fetusdiabetic macrosomic fetusRISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C What the Textbooks Recommend Conduct Conduct 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- matching of blood are more controversialThe issues of intravenous access and cross- matching of blood are more controversialRISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C What the Textbooks Recommend Conduct Conduct 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 contraindicatedRISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C What the Literature says Prostaglandins Prostaglandins “. Labor induced with prostaglandins confers the highest risk” “ 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 confers the highest risk” 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 2001 RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Personal Series Personal Series 31 following LSCS 1 followed myomectomy RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Personal Series 31 after LSCS 31 after LSCS In only three case did there appear to me to be no breach of duty RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Personal Series 31 after LSCS 31 after LSCS 9 mothers were injured 27 babies were either injured or died In 5 cases both mother and baby were injured RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Personal Series 9 Maternal Injuries 2 Hysterectomies (one with brain damage following prolonged shock) 1 Delayed hysterectomy (accreta) 5 Bladder Injuries (including two vesico-vaginal fistulae) 1 Psychiatric (following delayed recognition) RISK CLINICAL Roger V Clements Editor:Clinical Risk

V B A C Personal Series 27 Fetal Injuries 4 Stillbirths 9 Neonatal Deaths 14 Survivors with Cerebral Palsy RISK CLINICAL Roger V Clements Editor:Clinical Risk

The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest