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The AVMA Medical and Legal Journal

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Obstetrics & Gynaecology 78.4.727. RISK. CLINICAL. Roger V Clements. Editor:Clinical Risk ... Obstetrics & Gynaecology 78.4.727. RISK. CLINICAL. Roger V ... – PowerPoint PPT presentation

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Title: The AVMA Medical and Legal Journal


1
  • The AVMA Medical and Legal Journal
  • Incorporating
  • Healthcare Law Digest

2
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
3
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
4
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
5
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
6
V B A C
RISK
CLINICAL
  • Risk of Rupture
  • Is there a duty to warn?

Roger V Clements EditorClinical Risk
7
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
8
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
9
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
10
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
11
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
12
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
13
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
14
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
15
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
16
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
17
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
18
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
19
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
20
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
21
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
22
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
23
V B A C
RISK
CLINICAL
  • Personal Series
  • 31 following LSCS
  • 1 followed myomectomy

Roger V Clements EditorClinical Risk
24
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
25
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
26
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
27
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
28
  • The AVMA Medical and Legal Journal
  • Incorporating
  • Healthcare Law Digest
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