History
A woman is referred to the obstetric antenatal clinic by the community midwife after the
booking appointment revealed that she had had a previous emergency Caesarean. You are
the foundation year 2 doctor seeing her and you elicit the history and examine her.
She is 25 years old and pregnant with her second child. Her daughter was born 3 years ago by emergency Caesarean section for failure to progress in labour due to an occipito-posterior position. The pregnancy had been uncomplicated and she had gone into spontan-eous labour at 40 weeks 5 days. She had contractions for 24 h, and during this time she underwent artificial rupture of membranes and was given a syntocinon infusion for 8h. The cervix dilated to 8cm but she did not progress further despite regular strong contractions. Following the emergency Caesarean the baby was well, but the woman was readmitted to hospital after 7 days because of an infected wound haematoma for which she required intravenous antibiotics.
The antibiotics altered the taste of the breast milk and the baby subsequently had to have formula milk. She now feels anxious that she might have to go through the same experiences again and is wondering whether she can request an elective Caesarean section to avoid having another long labour and emergency procedure, with its associated complications. She has had no other pregnancies and is generally fit and healthy. She is currently 16 weeks’ gestation and has had a normal nuchal scan. Booking blood tests are normal.
Examination
The abdomen is distended, compatible with pregnancy. The low transverse scar is visible and is non-tender. The uterus is palpable to midway between the symphysis pubis and the umbilicus. The fetal heartbeat is heard with a hand-held Doppler machine.
Question
• How should you advise and manage her?
Medicine
The current average Caesarean section rate in the UK is approximately 24 per cent. This means that many women are returning in subsequent pregnancies having had a previous Caesarean section. In this case the woman has an otherwise low-risk pregnancy and the only factor to be considered at this stage is the planned mode of delivery. She should be able to make an informed choice after appropriate information regarding vaginal birth after Caesarean section versus planned Caesarean section. The important points for this woman to be informed about and to consider are summarized:
• vaginal birth after Caesarean (VBAC):
• successful in 70 per cent of cases
• emergency Caesarean section rate is approximately 30 per cent
• 1 in 200 risk of uterine rupture (scar dehiscence)
• close cardiotocograph monitoring is needed, with intravenous access, fasting and full blood count and group and save serum available
• normal progress is expected and augmentation of labour is not usually recom-mended in women with a uterine scar
• induction of labour may be appropriate in selected women with previous Caesarean section
• planned Caesarean section:
• operative delivery is associated with higher risks of haemorrhage, infection, visceral damage and thrombosis
• mobility and ability to care for child and baby is more impaired by Caesarean sec-tion than vaginal delivery
• planned Caesarean does avoid the possibility of an emergency procedure
• after two Caesarean sections a further Caesarean would be the only option in any subsequent pregnancy The woman should be offered a further appointment towards the end of the third trimester to confirm her decision regarding mode of delivery and to check for any complications that might contraindicate vaginal delivery such as breech presentation, a large baby, scar tenderness or pre-eclampsia. One of the most important points in the consultation is to lis-ten to her concerns about the previous delivery and what her fears might be. An empath-etic approach will help her to feel confident about any decision she makes this time.
KEY POINTS
• Although low, the maternal morbidity and mortality are higher for Caesarean section than for vaginal delivery.
• The chances of a successful vaginal delivery after a previous Caesarean section are 70 per cent
• A woman’s experiences of previous deliveries are very important in counselling for any subsequent pregnancy and delivery.
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