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Gaby’s Green Top Guidelines > 2015 45 Birth After Previous Caesarean > Flashcards

2015 45 Birth After Previous Caesarean Flashcards

1
Q

Which women are best suited for a VBAC?

A
  1. Majority!
  2. Singleton
  3. Cephalic
  4. 37/40+
  5. Single previous CS
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2
Q

What are the contraindications to VBAC?

A
  1. Previous uterine rupture
  2. Classical Caesarean scar (caution with T, J, low vertical & significant extensions)
  3. Absolute contraindications to vaginal birth eg placenta praevia
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3
Q

Can women with 2 or more Caesareans be offered VBAC?

A

Sometimes
With senior obstetric consultation
Individualised counselling

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4
Q

What are important features of antenatal VBAC counselling?

A
  1. Document final decision in advance of delivery date, latest 36/40
  2. Additional plan in case of spontaneous labour
  3. Consider VBAC checklist
  4. Patient information leaflet
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5
Q

What is the risk of uterine rupture in a) VBAC, b) unscarred uterus

A

a) 1:200
b) 2:10,000

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6
Q

Which risks are increased in VBAC compared to ERCS?

A
  1. Uterine rupture
  2. Greater adverse outcomes in EmCS after trial of VBAC
  3. HIE
  4. Perinatal death
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7
Q

Which risks are increased in ERCS compared to VBAC?

A
  1. Placenta praevia & accreta
  2. Pelvic adhesions
  3. Neonatal respiratory morbidity
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8
Q

How does IOL impact on the risk of a) uterine rupture b) EmCS, in VBAC?

A

a) 2-3x
b) 1.5x

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9
Q

What factors should be discussed with a senior obstetrician when considering IOL in VBAC?

A
  1. Decision to induce or augment
  2. Proposed method of induction
  3. Time intervals for serial VE
  4. Parameters of progress
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10
Q

In what special circumstances is there a lack of data about safety & efficacy of VBAC?

A
  1. Post-datex
  2. Twins
  3. Fetal macrosomia
  4. Antepartum stillbirth
  5. Maternal age over 40
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11
Q

How does preterm birth affect risks for VBAC?

A
  1. Similar success rates
  2. Lower risk of uterine rupture
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12
Q

Which types of uterine surgery are considered to have similar risks to VBAC?

A
  1. Myomectomy, lap or open
  2. Hysteroscopic resection of uterine septum
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13
Q

What are the risks of placenta praevia for different numbers of previous Caesareans?

A

1: 1% (0.6)
2: 1.7% (1.6%)
3: 2.8% (3.3%)

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14
Q

What are the risks of placenta accreta in women with placenta pravia & different numbers of previous Caesareans?

A

1: 11-14%
2: 23-40%
5+: 67%

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15
Q

What are the risks of requiring hysterectomy in a) VBAC for 1 previous CS b) VBAC with 2 previous CS?

A

a) 19 in 10,000
b) 56 in 10,000

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16
Q

Which risks are increased for VBAC with 2 vs 1 previous CS?

A
  1. Uterine rupture
  2. Hysterectomy
  3. Transfusion
17
Q

What factors I crease the risk of uterine rupture in VBAC?

A
  1. Inter-delivery interval < 12 months
  2. Post-dates
  3. Maternal age > 40
  4. Obesity
  5. Lower prelabour Bishop score
  6. Macrosomia
  7. Decreased lower segment myometrial thickness on US
18
Q

What % of women scheduled for ERCS go into labour before 39/40?

A

10%

19
Q

What are the maternal outcomes for planned VBAC?

A
  1. Success 72-75%
  2. Shorter hospital stay & recovery if successful
  3. Uterine rupture 0.5%
  4. Increased likelihood future vaginal birth
  5. OASI 5%
  6. Instrumental 39%
  7. Maternal death 4 in 100,000
20
Q

What are the maternal outcomes for ERCS?

A
  1. Planned delivery date
  2. Uterine rupture < 0.02%
  3. Longer recovery
  4. Reduction POP & urinay incontinence
  5. Option of sterilisation with advanced planning
  6. Future pregnancies: likely CS, increased placenta praevia & accreta, adhesions
  7. Maternal death 13 in 100,000
21
Q

What is the maternal death rate for a) planned VBAC, b) ERCS?

A

a) 4 in 100,000
b) 13 in 100,000

22
Q

What are the infant outcomes for planned VBAC?

A
  1. Transient respiratory morbidity less, 2-3%
  2. Antepartum stillbirth 1:1000, similar to spontaneous
  3. HIE increased, 8:10,000
  4. Perinatal death increased, 4:10,000
23
Q

What are the infant outcomes for ERCS?

A
  1. Transient respiratory morbidity increased, 4-5%
  2. Reduction in HIE & perinatal death, < 1:10,000
24
Q

What are the rates of successful VBAC in different situations?

A
  1. Overall 72-75%
  2. Previous vaginal birth 85-90%
  3. Reason, Fetal malpresentation 84%
  4. Reason, Fetal distress 73%
  5. Reason, Unsuccessful instrumental 61%
25
Q

How should women in established VBAC labour be managed?

A
  1. Supportive one-to-one care
  2. IV access
  3. FBC, G&S
  4. Continuous CTG
  5. Regular maternal obs
  6. VE at least 4-hourly
26
Q

If uterine rupture occurs, at what stage?

A
  1. 90% during labour
  2. Peak at 4-5cm
  3. 18% in 2nd stage
  4. 8% identified pist-vaginal delivery
27
Q

What are the clinical features of uterine rupture?

A
  1. Abnormal CTG
  2. Severe abdo pain, persisting between contractions
  3. Acute onset scar tenderness
  4. Abnormal PVB
  5. Haematuria
  6. Cessation of previously efficient uterine activity
  7. Maternal tachycardia, hypotension, fainting, shock
  8. Loss of station of presenting part
  9. Change in abdominal contour & position of FH

Gaby’s Green Top Guidelines (51 decks)

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