Costa Ribeiro, V

Nogueira Martins, F

Nogueira Martins, N

Repository of the Hospital Center of Central Lisbon

Outcomes of Vaginal Birth After Caesarean: Experience of a Portuguese Hospital

Repositório do Centro Hospitalar de Lisboa Central, EPE

Bruno Schauba,b,*aCentre Pluridisciplinaire de Diagnostic Pre´natal de Martinique,Centre Hospitalier et Universitaire de Martinique,Fort de France, FrancebService de Gyne´cologie Obste´trique, Maison de la Femme de la Me`reet de l’Enfant, Centre Hospitalier Universitaire de Martinique,Fort de France, FranceAlice MonthieuxService de Gyne´cologie Obste´trique, Maison de la Femme de la Me`re etde l’Enfant, Centre Hospitalier Universitaire de Martinique,Fort de France, FranceFatiha NajihoullahService de Virologie, Centre Hospitalier Universitaire de Martinique,Fort de France, FranceCaroline HarteService de Gyne´cologie Obste´trique, Maison de la Femme de la Me`re etde l’Enfant, Centre Hospitalier Universitaire de Martinique,Fort de France, FranceRaymond Ce´saireService de Virologie, Centre Hospitalier Universitaire de Martinique,Fort de France, FranceEuge´nie Joliveta,bJean-Luc Volume´niea,baCentre Pluridisciplinaire de Diagnostic Pre´natal de Martinique,Centre Hospitalier et Universitaire de Martinique, Fort de France,FrancebService de Gyne´cologie Obste´trique,Maison de la Femme de laMe`re etde l’Enfant, Centre Hospitalier Universitaire de Martinique, Fort deFrance, France*Corresponding author at: Centre Pluridisciplinaire de DiagnosticPre´natal de Martinique, Maison de la Femme de la Me`re et del’Enfant, Centre Hospitalier et Universitaire de Martinique, BP 632,97261 Fort-de-France, Martinique, France. Fax: +596 596 750530E-mail address: bruno.schaub@chu-fortdefrance.fr (B. Schaub).Received 14 October 2016http://dx.doi.org/10.1016/j.ejogrb.2016.10.041Outcomes of vaginal birth after caesarean:experience of a Portuguese hospitalDear Editors,In 2009, Portugal had a peak increase on caesarean rate to 32.9%[1], with no positive impact on maternal or neonatal mortality,being far from the World Health Organization recommendation of15%. A trial of labor after caesarean (TOLAC) provides an option toreduce morbidity in women who seek larger families and, whensuccessfully achieved, vaginal birth after caesarean (VBAC) yieldsless morbidity than a programmed repeated caesarean. In order tooffer proper counsel towomen in the pre-natal periodwe reviewedall VBAC in our Institution from January 2014 until December 2015(Table 1).Overall, VBAC represented 4.1% (n = 114; Table 1) of all vaginaldeliveries and although the reported induction rate was 22.8% itdid not add any major maternal or neonatal morbid-mortalitywhich could be related to the fact that the sample is not largeenough to discern a difference in rare events such as uterinerupture or neonatal asphyxia. In our review the labor inductiongroup had a higher percentage, although not statistically signiﬁ-cant (p = 0.140), of women with previous vaginal delivery (21.7%versus 10.2%) which we hypothesize to have had a positive impacton obstetrical outcomes. Besides Bishop Score and a past ofprevious vaginal delivery the risk of uterine rupture in laborinduction seems to be also dependent on the induction method ofchoice. In our population prostaglandin E2 (PE2) was the mostcommonly used (20.2%). Between induction methods, oxytocinadds the lowest risk of uterine rupture (1.1%) [2], nevertheless andaccording to Cahill et al. (2008) [3] multicentre, retrospectivecohort study of 25 000 women, the risk seems to be doseTable 1Global evaluation of VBAC (n=114).n %Maternal age, yearsa 31.84.9BMIa, kg/m2 29.35.0<30kg/m2 66 57.930kg/m2 43 37.7Weight gain in pregnancya, kg 11.85.6Obstetrical pathologyHypertensive disorders 3 2.6Diabetes 14 12.3Others 1 0.9Obstetrical backgroundPrevious vaginal delivery 14 12.3Clinical motive for previous caesareanAbnormal fetal presentation 27 23.7Fetal distress 31 27.2Labor dystocia 43 37.7Failed labor induction 2 1.8Obstetrical pathology 7 7.0Current gestationGestational age at deliverya 39.41.2Spontaneous labor 88 77.2Induction of labor 26 22.8Oxytocin 3 2.6Prostaglandin E2 23 20.2Rupture of membranes previous to admission 43 37.7Meconium 3 2.6Labor augmentationOxytocin 60 52.6OutcomeEutocic delivery 53 46.5Operative vaginal delivery 61 53.5Dystocia 52 45.6Fetal distress 9 7.9Apgar score58 Minute >7 114 100New-born weighta 3256.1563.5Maternal morbid–mortalityMajor morbidityb 0 0Minor morbidityc 20 17.5a Data are given as mean standard deviation.b Maternal death, hysterectomy, uterine rupture and admission to intensive careunit.c Intrapartum fever (n=1), perineal tear third degree (n=5), cervical laceration(n=1), vaginal hematoma (n=3), uterine atony (n=3), retained placenta (n=3),endometritis (n=3) and episiotomy dehiscence (n=1).Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 235–246 241dependent with an estimated incidence of 2.9% and 3.6% fordoses above 20 and 30 mU/min, respectively. Labor inductionwith prostaglandins is associated with 1.4% [2] risk of rupture.Prostaglandin E1 is not currently recommended since Wing et al.(1998) trial of 17 patients showed a rate of uterine longitudinalrupture of 11.8% [4]. Although the clinical use of PE2 remainscontroversial in our review it was not associated to uterinerupture however besides the small sample size anotherweakness is the lack of Bishop Score since among studiesit remains unclear whether the increased risk of rupture isdue to an unfavourable bishop or the method of inductionitself.In a secondary analyses obese women had no increased rates ofoperative vaginal delivery or associated morbid-mortality never-theless this should be interpreted with caution since obesity grouphad a higher proportion of women with a prior vaginal delivery(18.6% versus 6.1%; p = 0.042). Interestingly obese women had asmaller proportion of women with spontaneous labor (65.1%versus 84.8%; p = 0.017) and delivered in a later gestational age(39.8  1.0 versus 39.2  1.2; p = 0.011) which might be related topoorer uterine contractility. According to published data, obesity isassociated with high cholesterol levels which modiﬁes the viscosityand membrane ﬂuidity with a consequent disturbance in calciumintracellular transport leading to diminished uterine contractilityseen is obese [5].Throughout our study we found no predictive factors ofoperative VBAC including maternal and gestational age, inductionof labor or clinical indication of previous caesarean.When attempting VBAC, obstetrical characteristics should betaken into account for patient counseling regarding the risks andbeneﬁts of TOLAC. Although the use of PE2 showed to be safe wewere not able to correlate it with an initial cervical examination.Nevertheless, when facing a favorable Bishop Score, induction oflabor should be seriously considered. To the best of our knowledge,an unfavourable cervical examination enhances the risk of uterinerupture prompting the consideration for the need of mechanicalcervical methods that ripen the cervix with no immediate uterinecontractility associated.References[1] Direc¸a˜o Geral da Sau´de. Indicadores e metas do PNS. http://impns.dgs.pt/nascer-com-saude/ [accessed 08.06.16].[2] Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomesassociated with a trial of labor after prior caesarean delivery. National Instituteof Child Health and Human Development Maternal-Fetal Medicine Units Net-work. N Engl J Med 2004;351:2581–9.[3] Cahill AG, Waterman BM, Stamilio DM, et al. Higher maximum doses ofoxytocin are associated with an unacceptably high risk for uterine rupturein patients attempting vaginal birth after cesarean delivery. Am J ObstetGynecol 2008;199. 32.e1.[4] Wing DA, Lovett K, Paul RH. Disruption of prior uterine incision followingmisoprostol for labor induction in women with previous caesarean delivery.Obstet Gynecol 1998;91:828.[5] Wray S, Jones K, Kupittayanant S, et al. Calcium signalling and uterine contrac-tility. J Soc Gynecol Investig 2003;10:252–64.Vania Costa Ribeiroa,b,*aCentro Hospitalar Tondela-Viseu, Hospital Sa˜o Teoto´nio,Departamento de Ginecologia-Obstetrı´cia, Viseu, PortugalbCentro Hospitalar Lisboa Central, Maternidade Dr. Alfredo da Costa,Lisbon, PortugalNuno Nogueira MartinsFrancisco Nogueira MartinsCentro Hospitalar Tondela-Viseu, Hospital Sa˜o Teoto´nio,Departamento de Ginecologia-Obstetrı´cia, Viseu, Portugal*Corresponding author at: Centro Hospitalar Lisboa Central,Maternidade Dr. Alfredo da Costa, Lisbon, PortugalE-mail address: dokvcr@gmail.com (V. Costa Ribeiro).Received 3 October 2016http://dx.doi.org/10.1016/j.ejogrb.2016.10.040Use of a laparoscopic specimen retrieval bag fordelivery of an entrapped head in a breech fetusat 21 weeks gestationDear Editors,A 29 years old nulliparous patient presented to delivery suite at21 weeks gestation complaining of vaginal bleeding. She was lowrisk at booking except for a BMI of 31, and had routine antenatalcare. A speculumexaminationwas performedwhich showed bloodstained liquor. The patient was admitted and an ultrasound scanrevealed a live fetus with oligohydramnios and absent enddiastolic ﬂow on Doppler. The patient and her husband werefully counselled by a consultant about the risks of continuing thepregnancy versus elective termination. The couple suffered frominfertility, and had been trying for 9 years. There were no signs oflabour. They therefore requested 24 h to consider their options,during which they remained on the antenatal ward.Eight hours later the patient’s husband requested assistancefrom themidwife caring for her. On arrival in the room themidwifenoted feet protruding from the vagina. The oncall registrarattended and found the fetus delivering as a breech, with theumbilicus at the level of the introitus. The patient was encouragedto push, but no further descent of the body occurred. Vaginalexamination revealed the cervix was only partially dilated withboth arms stuck in the cervix behind the fetal head. The arms weregently delivered and the patientwas again encouraged to push. Thefetus remained undelivered, and further examination conﬁrmedhead entrapment. The cervix could not be encouraged to stretcheither with pushing or gentle manipulation with ﬁngers. Gentletraction on the fetus caused tearing of the skin at the junction of theneck and shoulders.The patientwas transferred to theatre and a general anaestheticwas administered. As the fetus was non-viable and the couple hadlong standing fertility issues it was important to deliver an intactfetus as the patient wished to view it, yet we did not want to causeany potential long term complications to the mother. It wastherefore decided we should avoid Du¨hrson’s Incisions andcaesarean section/hysterotomy if at all possible.We therefore passed a specimen retrieval bag, usually usedduring laparoscopic surgery, between the fetal head and theoperator’s index ﬁnger. The retrieval bag was rotated within theuterus so that it opened next to the fetal head. The aperture wasmoved so that it was enclosing the fetal head and the bag drawnclosed in the usual way. Gentle traction to the bag effectedpressure to the top of the head rather than the shoulders allowingthe head to gently dilate the cervix and the fetus to be deliveredsuccessfully with no cervical trauma.The fetus was delivered intact with no obvious injuries from thespecimen retrieval bag. Careful examination of the mother’s cervixand vagina also revealed no evidence of trauma from the technique.The family were given the opportunity to view and grieve for anintact fetus, which is important as an opportunity to bond is nowroutine practice in the management of late miscarriages and stillbirths.Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 207 (2016) 235–246242

Outcomes of Vaginal Birth After Caesarean: Experience of a Portuguese Hospital

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Repositório do Centro Hospitalar de Lisboa Central, EPE