TEMPLATE DESIGN © UNSCHEDULED ADMISSIONS AND DELIVERY IN WOMEN WITH PRIOR CAESAREAN BIRTH AND PLANNED FOR DELIVERY BY ELECTIVE CAESAREAN M Suchetha, R Jameison; Princess Royal Maternity Hospital,Glasgow, United Kingdom References Timing of elective caesarean section has become increasingly important as more and more women now request caesarean. Benefits of delayed caesarean need to be balanced against risk of spontaneous labour prior to planned date of delivery for women with prior CS. Although the number of patients in the study was small, a significant number of women delivered between 38 and 39 weeks of gestation [28/60].Delivering women identified to be in labour sooner may prevent some complications like a difficult second stage caesarean section. Effort should be taken whenever possible to reduce risks of emergency caesarean in women with prior caesarean. Larger studies can provide more evidence. Background : Up to 10% women go into labour prior to the scheduled date at 39 weeks. When patients choose elective repeat caesarean section they may expect to avoid maternal as well as fetal complications that can occur during labour. Results: 60 patients were identified. 82% had one, 13% had two and the rest three previous CS. 15% had a history of a previous vaginal delivery. In 82% CS was planned for 39 weeks of gestation. The rest were planned for CS between weeks due to other complications of their pregnancy. Reasons for admission : Majority [47%] needed admission at 38 weeks. 48% presented with symptoms of labour, 17% with symptoms of PROM, and others with APH[5%], decreased fetal movements[1/60], and monitoring for medical complications [6.6%]. Management on admission : Most women were seen by medical staff within 45 minutes of admission. 28% were diagnosed to be in labour at admission. From triage 28% were admitted to labour ward, 67% to the maternity ward and one went straight to theatre. 40% went into labour whilst being observed as inpatients and another 18% showed evidence of fetal distress. 30% were delivered within 6 hours of admission. Urgency of CS was category one in 5% and category 2 in 35%. Aims : To Identify the reasons for unscheduled admissions, whether these women were promptly seen and managed, whether they experienced any complications, and their mode of delivery. Place of study : Maternity unit, Princess Royal Maternity Hospital Glasgow Study design : Retrospective analysis of case notes Study period : 12months starting from 1 st December 2009– 31 st November 2010 Methods :All patients who were booked for elective caesarean but were admitted and delivered prior to the planned date were identified from the booking folder kept in the Labour Ward and the Operations Register kept in the maternity theatre. Also a list was generated from PROTOS, the computerised data system of patients who were scheduled for CS category 4 but delivered by category 1-3. Case notes were collected with the help of medical records department in our hospital. Theatre1 Labour ward17 Antenatal ward40 Table 6: Admission after triage Evidence of labour24 Fetal distress11 Raised Blood pressure1 Antepartum haemorrhage3 Table 7: Concerns while in patients in the ward SVD1-CS1-SVD11 SVD1-CS31CS1-SVD1 1 SVD1-CS12CS1-FD1 1 FD1-CS12 CS1-VD1-CS11 Table 2: Number of previous vaginal & caesarean deliveries SVD –spontaneous vaginal delivery FD –forceps delivery CS -caesarean < 6hours hours hours hours3 2 days2 4 days1 Table 8: Interval between admission and delivery Table 11: Decision delivery interval in caesareans Ventouse3 Midcavity forceps3 Keilland’s rotational forceps1 Preterm spontaneous vaginal1 Caesarean52 Table 9: Mode of delivery Leaking fluid vaginally10 [6preterm] Contractions29 [5 preterm] APH3 Decreased fetal movement1 Muscle pain, epigastric pain1 others4* Table 3: Presenting complaint *elective admissions for medical conditions like pre-eclampsia, diabetes, oligohydramnios,or for steroids but needed early delivery due to spontaneous labour or suspected fetal distress prior to the scheduled date/time No evidence of labour10 Active labour2 Early labour9 SROM, early labour3 [breech-1] SROM9[meconium-2, preterm-3]] Preterm labour3 APH3 [placenta praevia-1, abruption-1] Muscle pain, gastritis1 others4* [as above] Table 4: Diagnosis Not recorded19 Table 10: Urgency of caesarean <30 min min min min2 3 hours1 4 hours1 5 hours1 Those who had vaginal delivery did not want VBAC earlier but changed when labour progressed especially when found to be in 2 nd stage. Scar dehiscence 3* [1 was complete, baby’s face presenting at laparotomy] Hole in lower segment1 Longitudinal tear lower segment 2 Angle extension1 Major blood loss3 [ 1 abruption –ITU] Acute stress disorder/?psychotic 1 Poor Apgars3 Thick meconium2 Special care baby unit5 [2 preterm] One patient who was an in patient overnight was found to be fully dilated during a routine preoperative ward round by the elective caesarean registrar. There was one stillbirth which was due to severe antepartum haemorrhage and abruption in a previous two caesarean patient inspite of urgent caesarean. There were no other adverse outcomes to babies related to delivery. Many of the patients were inpatients for several hours and had to be delivered overnight due to various concerns. Consultants were called in for the major complications. Table 12: Complications Conclusion Acknowledgements : Dr Phil Owen, M Leonard, B Sutherland Birth after caesarean section, Feb 2007 ; RCOG Green top guideline. 1 st previous CSFailure to progress in labour19[6-2 nd stage] Fetal distress12 abruption2 PET & eclampsia5 breech4 IUGR4 Placenta praevia2 PPROM1 2 nd previous CSPPROM1 Placenta praevia1 Previous CS4 NR2 Table 1: Indications for previous caesareans Table 5: Gestational age in weeks at presentation APH - antepartum haemorrhage SROM – spontaneous rupture of membranes