Case 23 A 26-year-old woman with a history of one previous caesarean section booking at the antenatal clinic

Case 23 A 26-year-old woman with a history of

one previous caesarean section

booking at the antenatal clinic

Mrs Mclean is a 26-year-old woman, booking at the

antenatal clinic in her second pregnancy at 13 weeks’

gestation. Her booking scan is normal. Her first pregnancy

culminated in an emergency caesarean section 2 years ago.

What other information would

you need?

The details of her previous labour and operation.

Indication for the previous caesarean section

Was it for a recurrent or non - recurrent indication?

There are very few recurrent indications (e.g. severely

contracted pelvis). Most caesarean sections are for non -

recurrent indications which include breech presentation,

fetal distress and non - progress of labour.

Type of caesarean section (lower or upper

uterine segment caesarean section)

Most caesarean sections are performed through the lower

segment of the uterus (Fig. 23.1 ). The few indications for

an upper segment (classic) caesarean section include one

that may need to be performed at a very preterm gestation where the lower segment is not well formed, for a

transverse lie with rupture of membranes and no liquor

to manipulate the fetus or for a major placenta praevia.

Intraoperative or postoperative complications

Intraoperative complications include extension of the

lower uterine segment incision or injury to the bladder,

bowel or increased bleeding or uterine atony at caesarean

section. Postoperative complications include infections

(endometritis, pelvic infection, superficial wound infection or of other systems including chest infections) or

thrombosis.

Mrs Mclean has had an uncomplicated lower segment

caesarean at 7cm cervical dilatation for fetal distress. The

postoperative period was uneventful. The birth weight of

her son was 3.7kg.

How would you counsel her?

She should be given the choice of trial of labour (vaginal

birth after caesarean section [VBAC]) or elective repeat

caesarean section (ERCS) as she has had a lower segment

caesarean section for a non - recurrent indication. Maternal and perinatal benefits and risks of VBAC and ERCS

should be discussed.

Successful VBAC occurs in 72 – 76% of women attempting it, with a 24 – 28% chance of requiring an emergency

caesarean section. Successful VBAC has the advantage of

shorter hospital stay, quick recovery and good chance of

vaginal delivery in subsequent pregnancies. Also, the risk

of the baby having respiratory problems after birth is

reduced with VBAC.

VBAC carries a risk of uterine rupture of 22 – 74/10,000

with one previous caesarean section (Box 23.1 ). There is

no risk of uterine rupture in women undergoing ERCS.

The risks of scar rupture with two previous caesarean

sections is not clearly known (approximately 92/10,000).

There is also an additional 1% risk of blood transfusion,

endometritis and 2 – 3/10,000 additional risk of birth -

related perinatal death with VBAC when compared with

ERCS. ERCS carries the risk of bleeding, infection,

thromboembolism, operative injury and may increase

the risk of serious complications in future pregnancies.

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.

KEY POINT

Timing of elective caesarean section. Caesarean section

should be carried out after 39 weeks to decrease the risk

of neonatal respiratory distress syndrome.Case 23 149

PART 2: CASES

Mrs Mclean fully understands the advantages and

disadvantages of VBAC and ERCS. She is very keen for a

vaginal delivery at home.

What would you advise her?

She should be advised to deliver in the hospital as VBAC

should be conducted in a suitably staffed and equipped

delivery suit, with continuous intrapartum and electronic

fetal monitoring with immediate access to caesarean

section, neonatal resuscitation and on - site blood

transfusion.

Mrs Mclean does not want any risk to herself or the baby

and now wishes a VBAC in the hospital. She wants to know

the options for pain relief in labour.

What pain relief options are available

to her in labour?

She has the option of using Entonox, morphine, transcutaneous electrical nerve stimulation (TENS) or epidural.

Epidural analgesia is not contraindicated with VBAC.

Further antenatal appointments are with the community

midwife. She has the serum screening for Down’s syndrome

at 16 weeks which puts her in the low risk category and her

20-week detailed anomaly scan is normal.

When would you wish to see her in the

antenatal clinic and what investigation

would you arrange before the review?

An antenatal review around 36 weeks gestation to discuss

her decision about mode of delivery and evaluate any risk

Figure 23.1 Lower segment caesarean section.

(a)

(b)

(c)

(d)

Abdominal wall

Uterine membrane

Forceps

Retractor

Placenta

Uterus Incision in

uterus

Incision in

peritoneum

Box 23.1 Contraindications to VBAC

• Previous one classic (upper segment) caesarean section

• Three or more previous caesarean sections

• Previous uterine rupture or scar dehisence150 Part 2: Cases

PART 2: CASES

factors that would exclude a VBAC would be indicated.

If at her 20 - week scan the placenta has been documented

to be implanted anteriorly on the uterus, she would need

an ultrasound to rule out a low lying placenta (see Case

17 ; previous caesarean section is a risk factor for a low

lying placenta which may also be adherent if implanted

over the old scar).

Mrs Mclean is seen by the community midwife at 24, 28

and 32 weeks. The ultrasound at 36 weeks confirms the

placenta to be fundal and anterior with normal growth and

liquor. Her final decision about the mode of delivery is to

have a vaginal delivery. Rest of her antenatal care is with the

community midwife who refers her to the antenatal clinic at

41 weeks (postdates) to discuss induction of labour.

What options does she have?

She has the option of ERCS or induction of labour (artificial rupture of membranes with oxytocin augmentation

or prostaglandin cervical ripening, depending on cervical

Bishop ’ s score) at 41 – 42 weeks.

What advice would you give her about

induction of labour?

There is two - to threefold increased risk of uterine

rupture and 1.5 - fold increased risk of caesarean section

in induced or augmented labours compared to spontaneous labour. There is higher risk of uterine rupture with

induction of labour with prostaglandins than with non -

prostaglandins (2.4% vs 0.8%.).

How would you manage her initially?

• Intravenous access, full blood count (FBC) and group

and save

• Abdominal examination and cardiotocograph (CTG)

monitoring

• Sterile speculum examination to confirm rupture of

membranes

• Cervical assessment to determine the stage of labour

Two to three mild to moderate uterine contractions are felt

every 10 minutes. The CTG is reassuring. Vaginal

examination shows the cervix to be 4cm dilated, fully

effaced with the presenting part 2cm above the spines.

Clear liquor is seen draining and the membranes are

confirmed to be ruptured.

What should be the subsequent

management?

• Continuous CTG monitoring

• Regular assessment of uterine contractions

• Careful serial cervical assessment, preferably by the

same person, to ensure there is adequate progress in cervical dilatation and descent of the fetal head in the maternal pelvis

• Monitor for signs of uterine rupture (Box 23.2 )

Subsequent vaginal examination, 6 hours from the initial

examination, shows the cervix dilatation still at 4cm, with

the presenting part at –2 station in an occipito-transverse

position. Two mild contractions are felt every 2 minutes.

There are no signs of scar rupture. After appropriate

counselling (to reinforce the risks of scar rupture with

augmentation of labour with oxytocin), in view of the

Box 23.2 Concerning clinical features of utering

rupture

• Abnormal CTG

• Severe abdominal pain, especially if persisting between

contractions

• Chest pain or shoulder tip pain, sudden onset of

shortness of breath

• Acute onset of scar tenderness

• Abnormal vaginal bleeding or haematuria

• Cessation of previously effective uterine contractions

• Maternal tachycardia, hypotension or shock

• Loss of the station of the presenting part in the

maternal pelvis

KEY POINT

The decision to induce and the method chosen should be

consultant led.

On discussing the options Mrs Mclean opts for induction of

labour. Vaginal examination shows the cervix to be 2cm

dilated, 1cm long (50–60% effaced), soft, mid-position and

the station of the presenting part at 2cm above the ischial

spine (Bishop’s cervical score of 7 ‘favorable cervix’; see

Case 14 ).

A membrane sweep is performed and she is booked for

artificial rupture of membranes and oxytocin augmentation

at 10 days past the expected date of delivery. She presents

to labour ward the next day with spontaneous rupture of

membranes and contractions.Case 23 151

PART 2: CASES

non-progress of labour, oxytocin intravenous infusion is

commenced for augmentation of labour at Mrs Mclean’s

request. Repeat vaginal examination 4 hours after regular

contractions shows no change in the cervix or in the

position or station of the head despite strong and regular

contractions. The CTG is reassuring.

What would you advise her now?

In view of failure to progress despite strong and regular

contractions, she should be advised an urgent caesarean

section (Box 23.3 ).

Mrs Mclean consents to go ahead with a caesarean section.

She also makes a request for sterilization at the time of

caesarean section.

What would you advise her about

sterilization and what preoperative

assessment should be performed?

She should be advised that for sterilization to be performed at the time of caesarean section, counselling and

agreement should have been given at least 1 week prior

to the procedure, and should not be not be considered

for the first time in an emergency situation. She should

have had time to consider the permanence of the procedure, the failure rate of about 1 in 300, the small risk of

future ectopic pregnancies and menstrual irregularities,

and the alternative methods of reversible contraception.

Preoperative assessment involves:

• Checking haemoglobin level on FBC

• Prescribing of prophylactic antibiotic (one intraoperative dose of cephalosporin or augmentin)

• Assessing thromboembolic risk

• Siting an indwelling catheter

• Offer antiemetic, antacid and H2 receptor analogues

• Anaesthetic review – offer regional anaesthesia and

discuss postoperative pain relief

Mrs Mclean has an uncomplicated urgent lower segment

caesarean section under spinal anaesthesia. A male baby

weighing 3.8kg with good Apgar scores of 9/10 and 9/10

at 1 and 5 minutes is delivered. She receives intraoperative

prophylactic antibiotics. The total blood loss is 780mL. She is

prescribed a prophylactic dose of dalteparin postoperatively.

What postoperative care should

she receive?

• Offer patient - controlled opioid analgesia (PCA) or

oral opioids for pain

• Offer a non - steroidal anti - inflammatory drug (NSAID)

to reduce the need for opioids

• Additional support to start breastfeeding as soon as

possible

• Urinary catheter could be removed 12 hours after

spinal or last top - up of epidural analgesia

• She should eat and drink when hungry or thirsty

• If she recovers well and remains apyrexial she could be

discharged home on the second or third postoperative

day with follow - up by the community midwife

• Discuss the reasons for caesarean section and implications before discharge

• Discuss contraception

Mrs Mclean makes a good recovery postnatally and is

discharged home on the third postoperative day. Her

haemoglobin at discharge is 98g/L and she is commenced

on oral ferrous sulphate tablets. On discussing the

contraceptive options, she opts for an Implanon implant

which could be inserted by the GP or in the family planning

clinic. In any subsequent pregnancy, because of her history

of two previous caesarean sections, an elective caesarean

section is an option for her, although if she were very keen

she might be able to opt for another VBAC (understanding

the risks especially of scar rupture), especially if she labours

spontaneously.

Box 23.3 Classification of urgency of caesarean

section

Emergency caesarean section

Immediate threat to the life of the mother or the fetus

(delivery should be accomplished within 30 minutes), e.g.

placenta abruption, cord prolapse, profound or prolonged

fetal bradycardia

Urgent caesarean section

Maternal or fetal compromise that is not immediately

life-threatening, e.g. none or slow progress of labour

where the mother and fetus are in good condition

Scheduled caesarean section

No maternal or fetal compromise, but needs early delivery,

e.g. breech presentation at term with ruptured

membranes, but not in labour

Elective caesarean section

Delivery timed to suit woman or staff, e.g. planned

caesarean section for breech presentation at term or for

previous two caesarean sections152 Part 2: Cases

PART 2: CASES

ObGyncases (Healthcare Touch)

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Case 23 A 26-year-old woman with a history of one previous caesarean section booking at the antenatal clinic

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