PREVIOUS CAESAREAN SECTION
A
woman is referred to the obstetric antenatal clinic by the community midwife after the booking appointment revealed that
she had had
a previous emergency Caesarean. You are
the foundation year
2 doctor seeing
her and you
elicit the history
and examine her.
She
is 25 years old and pregnant with her second
child. Her daughter
was born 3 years
ago by emergency Caesarean section
for failure to progress in labour due to an occipito-
posterior position. The pregnancy had been uncomplicated and she had gone into spontan-
eous labour at 40 weeks
5 days. She had contractions for 24 h, and during
this time she underwent artificial rupture of membranes
and was given a syntocinon infusion for 8 h. The cervix dilated to 8 cm but she did not progress
further despite regular strong contractions.
Following the emergency Caesarean the baby was
well, but the
woman was readmitted to hospital after 7 days because
of an infected wound haematoma
for which she required
intravenous antibiotics.
The
antibiotics altered the
taste of the
breast milk and
the baby subsequently had to have formula milk.
She
now feels anxious
that she might
have to go through the
same experiences again
and is wondering whether
she can request
an elective Caesarean section to avoid
having another long labour
and emergency procedure, with its associated complications.
She
has had no other pregnancies and is generally
fit and healthy. She is currently 16 weeks’
gestation and has had a normal nuchal
scan. Booking blood
tests are normal.
The
abdomen is distended, compatible with pregnancy. The low transverse scar is visible and is non-tender. The uterus is palpable to midway between
the symphysis pubis
and the umbilicus. The
fetal heartbeat is heard with
a hand-held Doppler
machine.
·
How should you advise and manage her?
The
current average Caesarean section rate in the UK is approximately 24 per cent.
This means that many women are returning in subsequent pregnancies having had a previous
Caesarean section. In this case the woman
has an otherwise low-risk pregnancy and the only factor
to be considered at this stage is the planned
mode of delivery.
She
should be able to make an informed
choice after appropriate information regarding
vaginal birth after Caesarean section
versus planned Caesarean section.
The important points for this woman
to be informed about and to consider are summarized:
·
successful in 70 per cent of cases
·
emergency Caesarean section rate is approximately 30 per cent
·
1
in 200 risk of uterine
rupture (scar dehiscence)
·
close cardiotocograph monitoring is needed, with intravenous access,
fasting and full blood
count and group
and save serum
available
·
normal progress is expected and
augmentation of labour is not usually recom- mended in women with a uterine scar
·
induction of labour may be appropriate in selected women
with previous Caesarean section
·
operative delivery is associated with higher risks
of haemorrhage, infection, visceral damage and thrombosis
·
mobility and ability to care for
child and baby
is more impaired by Caesarean sec- tion than vaginal delivery
·
planned Caesarean does avoid
the possibility of an emergency procedure
·
after two Caesarean sections
a further Caesarean would be the only option
in any subsequent pregnancy
The
woman should be offered a further appointment towards the end of the third trimester to confirm her decision regarding mode of delivery and
to check for
any complications that might
contraindicate vaginal delivery
such as breech
presentation, a large
baby, scar tenderness or pre-eclampsia. One of the most important points in the consultation is to lis- ten
to her concerns about the previous delivery
and what her fears might
be. An empath- etic approach will help her to feel confident about
any decision she makes this time.
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