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Missed Opportunity
- Kaushal R Pandey (15 August 2004)
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Management dilemmas for VBAC
- Andrew J Drakeley, Mark D. Fraser, Obstetric SHO (16 August 2004)
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Kaushal R Pandey, Student 4th year TUTH, IOM
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The study is very releavent especially in the context that most common indication for delivery by cesarean section is a previous caesarian section. For the evidence in 1991 in Scotland 22% of deliveries performed were performed for the sole indication of previous caesarian section. Only 13.3%women in Scotland delivered vaginally after caesarian section (1). Most of the elective caesarian section performed in the second pregnancy was performed for the fear of uterine scar rupture. But after the lower segment uterine incision was devised, it became apparent that a vaginal delivery could occur both successfully and safely even though it was found by chance when a woman went in to labour before the scheduled repeat caesarian section and delivered before the operation could take place (2). The American college of obstetricians and gynecologists also recommends vaginal birth after caesarian section as a major strategy in reducing the proportion of caesarian births and formally endorsed a policy of trial of labour under most circumstances (3). The writers don’t explain for what indication the women went for repeated elective caesarian section. Neither is there comparison in outcome of vaginal delivery with those repeated elective caesarian section as the crux of the matter is whether to go for elective c/s or vaginal delivery in second pregnancy following a c/s and there are literatures(4) supporting that there is no significant difference in uterine rupture or dehiscence rate between elective repeat caesarian section and trial of labour.There is no comparison among those who were under trial of labour and underwent vaginal delivery successfully with those who had to be intervened by emergency surgery in terms of uterine rupture(it could occur in these case if it can occur in repeat elective c/s). There is no mention of the type of incision made, as the classical incision is associated with increased incidence of uterine rupture. The study does not talk on the matter if there were any indication for such incision and if so what was done in the second delivery with them. Some possible indication for classical caesarian section according to text books are preterm delivery with poorly formed lower segment, placenta previa or abruptio placenta with large vessels in the lower segment, PROM, transverse lie, large cervical fibroid, severe adhesions in lower segment reducing accessibility. Generally accepted contraindication for trial of labour is also diabetic macrosomic baby (2). Probably it is also associated with more chance of uterine rupture there by increased chance of perinatal mortality. The authors seem to have not used the opportunity in the same study to analyse these variables, at least if thes were not present,just to mention. References: 1. Norton FC, Cnattingius S, Bergsjo P et al (1994) Caesarian section delivery in: 1980’s. international comparison by indication. American Journal of obstetrics and Gynecology 170, 495-504. 2. James DK, Steer PJ, Weiner CP, Gonik B, editors. High Risk Pregnancy Management Options. 2nd edition, China , WB Sounders p:1205- 1216 3. ACOG Practice patterns (1995) Vaginal delivery after previous Caesarian Birth. International Journal of Gynecology and Obstetrics 52,90- 98. 4.Enkin M (1989) Labour and delivery following previous caesarian section . In:Chalmers I, Enkin M, Kierse MJNC,editors. Effective care in pregnancy and childbirth.p:1196-1215.Oxford:Oxford University Competing interests: None declared |
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Andrew J Drakeley, SpR Obstetrics and Gynaecology Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, Mark D. Fraser, Obstetric SHO
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Sir, We applaud the paper by Smith et al concerning factors predisposing to uterine rupture during attempted vaginal birth after caesarean section(VBAC) [1], (BMJ 2004; 329: 375-80 19th July). It will certainly assist in pre-labour counselling in the antenatal clinic. Whilst on duty last night on a labour ward which delivers 8000 women per year, several intrapartum management dilemmas arose. For women who are having a VBAC and whose progress in labour slows down, we feel it is a glaring omission for Smith et al not to comment on the use of intravenous oxytocin to augment these labours when discussing uterine rupture. In women who have not laboured before, which includes those who have had previous elective caesarean sections, dystocic labours are very common. O'Driscoll's seminal text 'The active management of labour' [2] pertains to nulliparous women with a singleton vertex presentation i.e. one baby head down!. In this Dublin based text the dystocic labour can be only one of three main causes, namely poor or incoordinate uterine contractions (assisted by oxytocin), malposition e.g. occipito-posterior, or cephalo-pelvic disproportion (diagnosed usually after 5cm cervical dilatation and after the use of oxytocin, requiring caesarean section). In addition various interventions, such as intra-uterine pressure catheters, which record the pressures generated by each contraction are used in the management of VBAC's with mixed popularity. Some address to these intrapartum issues would make a welcome addition to the literature. [1] Gordon C S Smith, Jill P Pell, Dharmintra Pasupathy, and Richard Dobbie, Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study BMJ 2004; 329: 375-80. [2] Kieran O'Driscoll, Declan Meagher and Michael Robinson. The Active Management of Labour (4th Edition). Mosby. Competing interests: None declared |
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