The AVMA Medical and Legal Journal

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• The AVMA Medical and Legal Journal
• Incorporating
• Healthcare Law Digest

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VAGINAL BIRTH AFTER CAESAREAN SECTION
RISK
CLINICAL

• Alternative Trial of Scar
• or Trial of Vaginal Delivery
• Not Trial of Labour

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Risk of Rupture
• (Meta Analysis - Dickinson)
• Enkin (1989) 4153 0.8
• Miller (1994) 10880 0.6
• Flamm (1994) 5022 0.8
• McMahon (1996) 3249 0.3

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Risk of Rupture
• (Meta Analysis - Clements)
• Rosen (1991) gt6000 c2
• Scott (1991) 196
  1.5
• ACOG (1994) ? 2.0
  

Roger V Clements EditorClinical Risk
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VAGINAL BIRTH AFTER CAESAREAN SECTION
RISK
CLINICAL

• Risks of Caesarean section
• Maternal Mortality of
• Elective Caesarean Section is of the order of 1
  in 10,000

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Risk of Rupture
• Is there a duty to warn?

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Risk of Rupture
• I am not aware of any credible VBAC study that
  did not report adverse outcomes.
• Gleicher N (1991) Letter. Obstetrics
  Gynaecology 78.4.727

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• 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 78.4.727

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Risk of Rupture
• The question is not whether uterine rupture
  occurs we know it does.
• Gleicher N (1991) Letter. Obstetrics
  Gynaecology 78.4.727

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Risk of Rupture
• The real question is, what incidence of adverse
  outcome are we willing to accept?
• Gleicher N (1991) Letter. Obstetrics
  Gynaecology 78.4.727

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Risk of Rupture
• Scott makes a valid point in stating that
  rupture rates are underreported.
• Gleicher N (1991) Letter. Obstetrics
  Gynaecology 78.4.727

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• 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 78.4.727

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• 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 53 11 661-662 1998

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• 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 53 11 661-662 1998

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• 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 53. 11 662-663 1998

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• 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 53. 11 662-663 1998

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• 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 53. 11 662-663 1998

Roger V Clements EditorClinical Risk
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V B A CWhat the Textbooks Recommend
RISK
CLINICAL

• Eligibility
• 1 previous lscs - no other adverse features
• Twins, breech non diabetic macrosomia
• More than one previous lscs is controversial
• Patient preference may influence choice

Roger V Clements EditorClinical Risk
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V B A CWhat the Textbooks Recommend
RISK
CLINICAL

• Eligibility
• Generally accepted contraindications include
• previous classical caesarean section
• diabetic macrosomic fetus

Roger V Clements EditorClinical Risk
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V B A CWhat the Textbooks Recommend
RISK
CLINICAL

• Conduct
• Critical review of progress of labour
• Continuous fetal heart rate monitoring
• The issues of intravenous access and
  cross-matching of blood are more controversial

Roger V Clements EditorClinical Risk
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V B A CWhat the Textbooks Recommend
RISK
CLINICAL

• Conduct
• Prostaglandins may be used - not any more!
• Caution should be exercised with oxytocin
• Regional analgesia not contraindicated

Roger V Clements EditorClinical Risk
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V B A CWhat the Literature says
RISK
CLINICAL

• Prostaglandins
• 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 34313-8 July5th 2001

Roger V Clements EditorClinical Risk
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V B A C
RISK
CLINICAL

• Personal Series
• 31 following LSCS
• 1 followed myomectomy

Roger V Clements EditorClinical Risk
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V B A CPersonal Series
RISK
CLINICAL

• 31 after LSCS
• In only three case did there appear to me to be
  no breach of duty

Roger V Clements EditorClinical Risk
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V B A CPersonal Series
RISK
CLINICAL

• 31 after LSCS
• 9 mothers were injured
• 27 babies were either injured or died
• In 5 cases both mother and baby were injured

Roger V Clements EditorClinical Risk
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V B A CPersonal Series
RISK
CLINICAL

• 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)

Roger V Clements EditorClinical Risk
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V B A CPersonal Series
RISK
CLINICAL

• 27 Fetal Injuries
• 4 Stillbirths
• 9 Neonatal Deaths
• 14 Survivors with Cerebral Palsy

Roger V Clements EditorClinical Risk
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• The AVMA Medical and Legal Journal
• Incorporating
• Healthcare Law Digest