TRIAL OF SCAR Is it ethical ? Is VBAC a legitimate aim for 2002 ? P. A Onyango- Okeyo Dept of Obstetrics & Gynaecology University of Witwatersrand

Introduction n Common obstetric event, 10-30% n Common indication, previous C/S n Historical n Review of the literature n Medical evidence indicates that 60-80% of TOL after a previous caesarean delivery result in successful vaginal births

VBAC Guidelines n Practical issues n Lowering the overall caesarean delivery rate n Practical problems

VBAC Guidelines n Antenatal n Appropriate hospital facilities for labour n Contraindications for VBAC n Candidates for trial of labour n Intrapartum management n Postpartum management

Antenatal n Booking and care n Decision for vaginal birth made at 36 weeks n Patient consent (points in counseling) 1.Reasons for the previous C/S 2.Type of uterine incision 3.Reasons to try for VBAC 4.Risks of VBAC 5.Reasons for and Risks of C/S 6.Other factors

Appropriate hospital facilities for labour n Staffing and equipment n Decision to delivery n Blood bank facility

Contraindications for VBAC n Patient request n Previous classical and Delee incisions n Previous Hystorotomy n Previous Myomectomy n Previous uterine rupture n Grossly contracted pelvis n Fetal size

C/I cont’d n Any medical or obstetric condition that precludes safe vaginal delivery 1.Presence of placenta previa, abnormal lie, multiple pregnancy 2.Medical conditions n Previous poor obstetric history n Previous C/S x 3 and greater n Facilities not available for emergency C/S

Suitability for trial of labour n Informed consenting patient n One previous low transverse C/S n Clinically adequate pelvis n Fetus of average size n No other uterine scar or prev rupture n Doctor immediately available n Availability of anaesthetist and support staff for emergency C/S n Blood bank service

Intrapartum management n Secondary or tertiary institution n Latent phase n Experienced midwife in attendance n Patient should have: 1.Venous access 2.Indwelling catheter 3.Analgesia 4.Partogram 5.Monitoring of parturient 6.Fetal monitoring

Intrapartum Mx cont’d n Pain and tenderness - unreliable indicators n Abandon TOL for emergency C/S if 1.Poor progress 2.Fetal heart abnormalities 3.Vaginal bleeding 4.Others

Second stage n Follow ordinary obstetric practices and procedures n Prolonged second stage should be avoided

Postpartum n Close observations for 2 hours n Manual exploration - inconclusive

Augmentation of labour n Literature review n Oxytocin n PGE2

Conclusion n Neither repeat C/S nor VBAC is risk free n If TOL is not going well then repeat C/S n Clinical guidelines will help each obstetrician evaluate, counsel and manage this obstetric subpopulation

A woman with a prior caesarean section is at increased risk, regardless of mode of birth, and eliminating VBAC will not eliminate the risks. Vigilance with respect to primary caesarean delivery is the only way to avoid this dilemma. B.L Flamm