THANK YOU SO MUCH!!! For all the help, I am hoping to get VBAC as an option for 2+ cs written in the state protocols.... wish me luck! For my next miracle I will change the sky colour! -perhaps I should do that first..it would be easier! lol Jo ----- Original Message ----- From: "CHERILLEE HARRY" <[EMAIL PROTECTED]> To: <[EMAIL PROTECTED]> Sent: Saturday, June 19, 2004 1:33 PM Subject: Re: [ozmidwifery] anyone have access to Blackwell Science?
> Hi, here's a copy of that study: > Australian and New Zealand Journal of Obstetrics and Gynaecology > Volume 43 Issue 6 Page 471 - December 2003 > doi:10.1046/j.0004-8666.2003.00131.x > > Case Report > Successful vaginal birth after three previous Caesarean sections with no prior labour > Lucy Bowyer 1,2 and Michael Chapman 1,2 > > Introduction > > Vaginal birth after Caesarean section is in danger of becoming extinct. Despite the spectre of litigation and bankruptcy we should maintain an evidence-based, rather than a litigation fearful, practice. To this end the present case illustrates the application of the best available evidence to a clinical challenge. > > Case report > > A 36-year-old woman consulted for a second opinion at 32 weeks' gestation in her fourth pregnancy. The woman wished to have a vaginal birth, having previously had three lower segment Caesarean sections. Her pregnancy had been uncomplicated with no vaginal bleeding; she was fit and well with a low body mass index. > > Her first baby (male 3.62 kg) was delivered in South Africa in 1994 by elective Caesarean section with an ante-partum diagnosis of 'cephalo-pelvic disproportion'. Her second baby (female 3.24 kg) was delivered by elective Caesarean section, again in South Africa, in 1996 for the indication of previous Caesarean section. In 1998 she and her family moved to the UK, she was keen to attempt vaginal birth and this was agreed provided that she laboured spontaneously before 42 weeks' gestation. At 42 weeks she had a third elective Caesarean section (female infant, 3.24 kg), as spontaneous labour had not occurred. > > The patient was very unhappy with the conduct of her previous deliveries. On each occasion the epidural had been difficult to insert, a spinal tap had occurred with the first baby and she felt bereft that she was unable to hold her babies (beyond the brief standard initial contact) and keep them with her. The consultation with her involved a review of published reports examining births after two or more previous Caesarean sections. It was obvious that she and her husband were already well informed with regard to the likely success of vaginal delivery and the possible uterine rupture rates. The opinion offered was a 60% chance of vaginal birth and a 3% risk of scar rupture with subsequent serious consequences. It was agreed that, after 6 h of active labour, if progress was poor then a Caesarean section would be advised. The risk of placenta praevia and percreta was discussed, and ultrasound revealed a posterior placenta well clear of the lower segment. As they wished to accep > t the risks involved, a vaginal birth after three previous Caesarean sections was planned at St. George Hospital, New South Wales, Australia. It was agreed that continuous fetal monitoring would be carried out throughout labour, if after 6 h of active labour delivery was not imminent then Caesarean section would be advised. At the 37-week visit the fetal lie was oblique; subsequently the lie became longitudinal with a cephalic, but unengaged, presentation at term. > > As she had been having short-lived contractions irregularly through the night and was fearful that intervention would be suggested she did not attend for her 41-week visit. However, she was persuaded to attend for an antenatal 42-week consultation. She had been having contractions overnight with only mild pain and felt well. The cervix was posterior, soft, 50% effaced and closed, the fetal vertex was 2 cm above the ischial spines, fetal movements and heart rate were normal. The increased risk of unexpected stillbirth as gestation prolongs was discussed, and she declined fetal ultrasound or cardiotocography. > > The following day at 42 weeks and 1 day gestation, she arrived in hospital in the evening, having had contractions that had become more painful and more regular throughout the day. On examination the cervix was 8 cm dilated, fully effaced and the fetal head at the ischial spines. She proceeded to have a normal vaginal birth 90 min later with a right medio-lateral episiotomy. A live male infant was born in excellent condition, weighing 3.565 kg. She and her husband were delighted with the outcome and she was discharged home on the early discharge program the following day. > > Discussion > > The largest reported series on birth after two or more previous Caesarean sections was by Miller et al. 1 Miller et al.'s study was conducted over a 10-year period in California and included 1586 women with two previous Caesarean sections undergoing a trial of labour; 1.8% (29) of these women had a uterine rupture, with one rupture-related perinatal death (0.63:1000). There were 241 women who had a trial of labour with three or more previous Caesarean section scars, with a rupture rate of 1.2% (three) and no perinatal deaths. The success of trial of labour in these groups was 75% and 79%, respectively. Within the same series the success for vaginal birth after Caesarean section with only one scar was 83% with a 0.6% uterine rupture rate and 0.18:1000 perinatal deaths, thus uterine rupture was more common in women with two or more Caesarean section scars. The maternal morbidity and hysterectomy rates are not stated in Miller et al.'s publication. There was one rupture-related > maternal death giving a rupture-related maternal mortality rate of 7.9 per 100 000 trials of labour and a 5.1% risk of perinatal asphyxia as a consequence of uterine rupture. > > The second largest series was by Phelan et al. and conducted over a 4-year period in California. 2 Trial of labour after two previous Caesarean sections was attempted by 501 women, with a 69% successful vaginal delivery rate. The uterine dehiscence rate is reported as 1.8% (less than the control group of repeat Caesarean sections who had a 4.6% dehiscence rate, with one uterine rupture), with no uterine ruptures and one hysterectomy carried out for uterine atony. The perinatal mortality rates from Phelan et al.'s series are hard to interpret as they included some very low birthweight infants (320-1990 g), but overall the perinatal mortality rate was comparable between women who did and who did not attempt a trial of labour. There were no maternal deaths. Interestingly, there were 85 women who had undergone a trial of labour in both previous pregnancies and, of these women, a trial was successful upon the third occasion in 53% (45) of cases. > > Undoubtedly a woman who has two or more previous Caesarean section scars in her uterus is at greater risk of uterine rupture than a woman who has only one scar. Appleton et al.'s Australian series estimates a rupture rate of 0.3% for women with one prior scar; thus there is a sixfold likely increase in the risk of uterine rupture in a woman with two previous scars, although the absolute figures are still only 1.8 per 100. 3 > > It is important to emphasise the serious consequences of rupture when counselling the individual woman. Where there are two previous Caesarean section scars, there is an approximate 2% risk of rupture necessitating hysterectomy and the possibility of fetal death. However, in the published reports these figures do not differ greatly from those women undergoing elective repeat Caesarean section, and should not exclude a trial of labour after two or even three previous Caesarean sections if that is what the fully informed individual woman desires. We must be aware of our limitations as clinicians to be all-protective and offer the best available advice from the best available evidence to our patients. > > References > > 1 Miller DA, Diaz FG, Paul RH. Vaginal birth after cesarean: a 10-year experience. Obstetrics Gynecol. 1994; 84: 255-258. > > 2 Phelan JP, Ahn MO, Diaz F, Brar HS, Rodriguez MH. Twice a cesarean, always a cesarean? Obstetrics Gynecol. 1989; 73: 161-165. > > 3 Appleton B, Targett C, Rasmussen M, Readman E, Sale F, Permezel M. Vaginal birth after Caesarean section: an Australian multicentre study. VBAC Study Group. Aust NZ J Obstet Gynaecol. 2000; 40: 87-91. > > Australian and New Zealand Journal of Obstetrics and Gynaecology > Volume 43 Issue 6 Page 471 - December 2003 > > Authors: > Lucy Bowyer > Michael Chapman > > ----------------------------------------------------------------------- --------- > > Received 10 July 2003; accepted 19 July 2003. > > Affiliations > > 1Department of Obstetrics and Gynaecology, St. George Hospital, Kogarah and 2University of New South Wales, New South Wales, Australia > > Correspondence > > Dr Lucy Bowyer, Department of Women's Health, Level 2, Prichard Wing, St. George Hospital, Gray Street, Kogarah, New South Wales 2217, Australia. Email: [EMAIL PROTECTED] > To cite this article > Bowyer, Lucy & Chapman, Michael (2003) > Successful vaginal birth after three previous Caesarean sections with no prior labour. > Australian and New Zealand Journal of Obstetrics and Gynaecology 43 (6), 471-472. > doi: 10.1046/ > j.0004-8666.2003.00131.x > > > ----- Original Message ----- > From: Dean & Jo <[EMAIL PROTECTED]> > Date: Friday, June 18, 2004 4:12 pm > Subject: [ozmidwifery] anyone have access to Blackwell Science? > > > I was just wondering if anyone can access this study? I cant > > unfortunatley!cheers > > Jo > > > > > > : Aust N Z J Obstet Gynaecol. 2003 Dec;43(6):471-2. Related > > Articles, Links > > > > > > Successful vaginal birth after three previous Caesarean sections > > with no prior labour. > > > > Bowyer L, Chapman M. > > > > Department of Obstetrics and Gynaecology, St. George Hospital, > > Kogarah, New South Wales, Australia. [EMAIL PROTECTED] > > > > Publication Types: > > a.. Case Reports > > > > PMID: 14712954 [PubMed - indexed for MEDLINE] > > > > -- > This mailing list is sponsored by ACE Graphics. > Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe. > -- This mailing list is sponsored by ACE Graphics. Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe.
