The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

1. The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

2. CLINICAL RISK VAGINAL BIRTH AFTER CAESAREAN SECTION Alternative: Trial of Scar or Trial of Vaginal Delivery Not Trial of Labour Roger V Clements Editor:Clinical Risk

3. CLINICAL RISK V B A C 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 Editor:Clinical Risk

4. CLINICAL RISK V B A C Risk of Rupture (Meta Analysis - Clements) Rosen (1991) >6000 c2% Scott (1991) 196 1.5% ACOG (1994) ? 2.0% Roger V Clements Editor:Clinical Risk

5. CLINICAL RISK VAGINAL BIRTH AFTER CAESAREAN SECTION Risks of Caesarean section Maternal Mortality of Elective Caesarean Section is of the order of 1 in 10,000 Roger V Clements Editor:Clinical Risk

6. CLINICAL RISK V B A C Risk of Rupture Is there a duty to warn? Roger V Clements Editor:Clinical Risk

7. CLINICAL RISK V B A C 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 Editor:Clinical Risk

8. CLINICAL RISK V B A C 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 Editor:Clinical Risk

9. CLINICAL RISK V B A C 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 Editor:Clinical Risk

10. CLINICAL RISK V B A C 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 Editor:Clinical Risk

11. CLINICAL RISK V B A C 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 Editor:Clinical Risk

12. CLINICAL RISK V B A C 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 Editor:Clinical Risk

13. CLINICAL RISK V B A C 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 Editor:Clinical Risk

14. CLINICAL RISK V B A C 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 Editor:Clinical Risk

15. CLINICAL RISK V B A C 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 Editor:Clinical Risk

16. CLINICAL RISK V B A C 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 Editor:Clinical Risk

17. CLINICAL RISK V B A C 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 Editor:Clinical Risk

18. CLINICAL RISK V B A CWhat the Textbooks Recommend 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 Editor:Clinical Risk

19. CLINICAL RISK V B A CWhat the Textbooks Recommend Eligibility Generally accepted contraindications include: previous classical caesarean section diabetic macrosomic fetus Roger V Clements Editor:Clinical Risk

20. CLINICAL RISK V B A CWhat the Textbooks Recommend 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 Editor:Clinical Risk

21. CLINICAL RISK V B A CWhat the Textbooks Recommend Conduct Prostaglandins may be used - not any more! Caution should be exercised with oxytocin Regional analgesia not contraindicated Roger V Clements Editor:Clinical Risk

22. CLINICAL RISK V B A CWhat the Literature says 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 343:1:3-8 July5th 2001 Roger V Clements Editor:Clinical Risk

23. CLINICAL RISK V B A C Personal Series 31 following LSCS 1 followed myomectomy Roger V Clements Editor:Clinical Risk

24. CLINICAL RISK V B A CPersonal Series 31 after LSCS In only three case did there appear to me to be no breach of duty Roger V Clements Editor:Clinical Risk

25. CLINICAL RISK V B A CPersonal Series 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 Editor:Clinical Risk

26. CLINICAL RISK V B A CPersonal Series 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 Editor:Clinical Risk

27. CLINICAL RISK V B A CPersonal Series 27 Fetal Injuries 4 Stillbirths 9 Neonatal Deaths 14 Survivors with Cerebral Palsy Roger V Clements Editor:Clinical Risk

28. The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest