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Clinical Review Evidence based case report

Use of prostaglandins to induce labour in women with a caesarean section scar

BMJ 1999; 318 doi: (Published 17 April 1999) Cite this as: BMJ 1999;318:1056

This article has a correction. Please see:

  1. Sarah Vause, specialist registrar,
  2. Mary Macintosh, consultant.
  1. Department of Obstetrics and Gynaecology, Leeds General Infirmary, Leeds LS1 3EK
  1. Correspondence to: Dr S Vause, Saint Mary's Hospital, Manchester M13 0JH
  • Accepted 12 November 1998

Mrs B, a 26 year old woman, was 10 days post term in her second pregnancy. Her first child had been delivered by elective caesarean section at 38 weeks' gestation because of a breech presentation. Two doses of prostaglandin E2 vaginal gel (1 mg), administered six hours apart, were used to induce labour. Eight hours after the second dose, Mrs B's cervix was found to be soft,fully effaced, and dilated to 3 cm, but her uterine contractions were mild and irregular. Amniotomy was performed and an infusion of oxytocin was started. Mrs B made good progress in labour with epidural analgesia.

Initially the fetal cardiotocograph was normal. However, four hours after the oxytocin infusion was started, fetal tachycardia with recurrent early decelerations was noted. At that time Mrs B's cervix was dilated to 9 cm. While preparations were being made for fetal scalp pH sampling, there was a prolonged deceleration in the fetal heart rate and fresh vaginal bleeding. Uterine rupture was suspected. Mrs B was transferred immediately to theatre, where this was confirmed. The baby showed no signs of life at delivery and could not be resuscitated. MrsB required a blood transfusion at the time of operation but made a good recovery afterwards.

When the case was discussed at the monthly perinatal meeting, it became apparent that the obstetricians had different views on the advisability of using prostaglandins to induce labour in women with a scarred uterus. Some doctors believed that the main benefit of induction over repeat elective caesarean section was that some women would achieve a vaginal delivery and the mode of delivery in subsequent pregnancies would not therefore be compromised. Others expressed concern that the risk of scar rupture after a previous lower segment caesarean section might be higher with prostaglandins than with other methods of induction. They suggested that the …

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