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

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

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

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

5. 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 *

6. 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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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 A V 7.11

16. 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

17. 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

18. 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: ( 17 April

19. 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),

20. 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. .

21. 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

22. 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.?

23. Where do we go from here?
There have been five recorded cases of uterine rupture since encountering my first in November 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

24. References
BMJ  2004;329:375 (14 August), doi: /bmj (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: /bmj
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: /bmj /g Synopsis...comparing the rate of diagnosis of uterine rupture in women with and without prior caesarean......
Am J Obstet Gynecol Oct;165(4 Pt 1): Links
Uterine rupture during trial of labor after previous caesarean section.

25. 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