AIMS Journal, 1990, Vol 2, No 2
Yvonne Williams & Sheila Tunstall
CAESAREAN SUPPORT NETWORK
We embarked upon this exercise with an open mind as we sent out the numerous letters to England, Wales and Ireland. The letter ally asked what is the policy in your unit on trial of labour? Do you insist on fasting in labour, intravenous drips, fetal heart monitoring and any other precautions?
"...I wish to inform you that all our previous L.S.C.S. are starved, have IV fluids and continuous monitoring when normal delivery is expected... "
The response that came back from the various units took us by shock. We were horrified that such extremeties existed in our labour wards. Everything the midwife told me was being implemented all over the country. At the present time a short list of radical obstetricians is being drawn up and it is so short that they can be counted on one hand.
Some units said a natural birth was possible, meaning to them that anything short of a caesarean section was a natural birth. Nearly all units considered women under- going a trial of scar to be 'at risk' and extra precautions were definitely necessary. A lot of units obviously had scar rupture at the front of their mind.
“...When you speak of a 'natural birth', I presume you mean a normal spontaneous vaginal delivery and this could certainly be the aim in patients following Caesarean section for non-recurring cause... “
Scar rupture I found to be a very controversial subject for although it played a large part in the minds and decisions of all medical staff, obstetricians, doctors, junior staff, midwives, nurses etc. there was little or no information to be found about this catastrophic condition. From the little research that I have been able to find about scar rupture, it was quite a problem with the old fashioned classical caesarean section with figures varying from 3% - 7%. If the scar ruptured following the classical section it could be devastating, but if the usual life-saving equipment is on hand then an emergency caesarean section can usually be performed to save the day.
“...May I say that these policies, in fact, refer to 'trial of scar' rather than 'trial of labour'. Trial of labour occurs for different reasons, usually not connected with previous Caesarean segment and so the policies are a little different..”
In the lower segment caesarean section however we have not yet found one case of complete scar rupture. The scar may part gently and almost asymptomatically along all or part of its length (more properly called dehiscence and not scar rupture). The scar may just blister or window which many doctors refer to as ruptures.
Unfortunately the two have never been differentiated and where the classical caesarean rupture can be catastrophic and life threatening the lower segment is usually silent, incomplete and requires no treatment. By the same token a repeat caesarean section is no safeguard against scar separation. So although the two are very different it seems very much as though hospitals base their decisions on the explosive type of scar rupture and all the usual interventions are to safeguard the scar going 'pop'. As I said we have never known it to happen and, lets face it, we only have their word for it that it has happened, as we cannot view inside the uterus!
“…We usually monitor the mother and babe carefully because there is a small incidence of scar rupture, which Of course is a very dangerous and urgent situation...”
Many units would not agree to a trial of scar if the woman was over a certain age. A lot differed with their thoughts of induction. Some felt scar rupture was more likely to occur if the uterus was stimulated with oxytocic drugs. Some were not so cautious and thought it made no difference to the incidence of scar rupture where others preferred induction to letting the baby go overdue. There are many contradicting ideas here, but who do we believe? Multiple pregnancy was a definite no no. If it was anything above a singleton pregnancy i.e. twins or the above, then trial of scar was definitely out.
“...Should a patient with a previous caesarean section require an induction of labour, this is carried out by artificial rupture of membranes followed immediately by Syntocinon infusion... “
“… The use of uterine stimulants in these patients should be undertaken with great caution… "
In short, a trial of scar is possible in a British hospital as long as there have been no complications after the first section, or with a second pregnancy. If the mother is healthy in the second pregnancy then trial of scar will probably be 'allowed', with the restrictions of fasting, intravenous drips, fetal heart monitoring etc.
CONCLUSION
Vaginal birth after Caesarean section - POSSIBLE
Natural birth following Caesarean section - HIGHLY UNLIKELY IN A BRITISH HOSPITAL.
Do AIMS or anybody have any ideas! Any suggestions of any description, and any stories about VBAC, trial of scar etc. are welcome.
AIMS Ed. Note: A full analysis and report of this 'policy survey' will be published in the AIMS Quarterly Journal later this year.
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