Vbac in palestine 07.feb.2016

A CLINACAL AUDIT

ON THE OUTCOME OF VBAC

IN A PALESTINIAN HOSPITAL

(HGH)

FACULTY OF MEDICINE

ALQUDS UNIVERSITY

SUPERVISED BY:

DR.FATIMA SHARABATI

OBS & GYN DEP. AT HGH

DONE BY:

YAHYA A. KHATEEB

LOTFI M. SROOR

MOATH M. MOUSA

RECS ( Repeat

Elective

Cesarean

Section )

METHOD

• Retrospective study done at Obs & Gyn Department at

Hebron Governmental Hospital, under supervision of

Dr.Fatima Sharabati, with approval of Dr. Hisham Amro,

Head of the department.

• Study done by clinical review of patients’ medical records

between 1st Nov 2015 until 18th Nov 2015.

With follow up for any reported medical complications on

both Mothers and Babies., in the first month post partum.

No. of cases Cases

excluded No. of previous 1

CS Elective

CS VBAC

tried Success

Failure

(urgent CS)

298 263 35 7 28 22 6

100% 88.3% 11.7% 20.0% 80.0% 78.6% 21.4%

Cases excluded 88.26%

Elective CS 2.35%

VBAC tried 9.40%

Cases of the study

Success 78.57%

Failure (urgent CS)

21.43%

Results of VBAC

0

1

2

3

4

5

6

7

8

15-19 20-24

25-29 30-34

35-39 40-44

AGE DISTRIBUTION

No. of success

No of cases included

Age No. of success No of cases included

15-19 1 1

20-24 3 7

25-29 6 8

30-34 5 7

35-39 5 7

40-44 2 5

No. of parity Success VBAC Failure of VBAC Elective CS

1 4 3 4

2 4 1 0

3 2 1 2

4 4 0 0

5 5 0 0

6 1 0 0

7 2 1 0

9 0 0 1

1 2 3 4 5 6 7

4 4

2

4

5

1

2

3

1 1

0 0 0

1

No

. o

f c

as

es

Parity

Parity vs. Success

Success VBAC Failure of VBAC

No. of NSVD before CS Success Failure

0 9 4

1 or more 13 2

1 2 1

2 4 0

3 3 0

4 1 0

5 3 0

6 0 1

Success 87%

Failure 13%

NSVD before CS

Success 69%

Failure 31%

No NSVD before CS VS.

VS.

( Para 1 , Previous 1 )

Success 93%

Failure 7%

With Hx of VBAC

Success 64%

Failure 36%

Without Hx of VBAC VS.

VS.

No of previous VBAC Success Failure

0 9 5

1 or more 13 1

1 10 0

2 1 1

3 1 0

4 1 0

0

1

2

3

4

5

6

7

26 27 31 32 37 38 39 40 41 42

Gestationl Age

GESTATIONAL AGE VS. SUCCESS

Success

Failure

WEIGHT OF BABY

Weight of baby Success Failure Elective

500 - 999 1 0 0

1000 - 1499 1 0 0

1500 - 1999 2 0 0

2000 - 2499 0 1 4

2500 - 2999 2 1 0

3000 - 3499 6 4 3

3500 - 3999 8 0 0

4000 - 4499 2 0 0

0 1 2 3 4 5 6 7 8

500 - 999

1000 - 1499

1500 - 1999

2000 - 2499

2500 - 2999

3000 - 3499

3500 - 3999

4000 - 4499

Weight of baby VS. Success

Failure

Success

INDICATIONS OF

ELECTIVE REPEAT OF CS

CS Type Indication Cases

Urgent (Failed VBAC) Pathological Trace 6

Breech 2

Low laying placenta 1

Placenta previa centralis 1

Previous 4th degree tear 1

IVF Twin 1

IVF Infertality 1

Elective

CS Type Indication Cases

Urgent (Failed VBAC) Pathological Trace 6

Breech 2

Low laying placenta 1

Placenta previa centralis 1

Previous 4th degree tear 1

IVF Twin 1

IVF Infertality 1

Elective

Maternal Request

(IVF Twin , IVF Infertility) 2

INDICATIONS OF

URGENT CS

(FAILED VBAC)

CS Type Indication Cases

Urgent (Failed VBAC) Pathological Trace 6

Breech 2

Low laying placenta 1

Placenta previa centralis 1

Previous 4th degree tear 1

IVF Twin 1

IVF Infertality 1

Elective

DISCUSSION

Results of our study where compared with VBAC Guidelines -2015,

prepared by National Institute for health and Care Excellence (NICE)

for Royal College of Obs & Gyn in UK.

DISCUSSION

• The success rate of VBAC in our study was : 78.6% , more

than the overall chance of successful planned VBAC

according to the Royal college guidelines, which was (72-

75%).

• Increased Parity number was associated with decrease

failure rates.

DISCUSSION

• High success rates in those had History of previous

normal delivery before their first CS (87%), and lower

success rate (69%) in those without any history of

previous normal delivery before the CS.

• High success rates in those had History of previous VBAV

(normal delivery) after their first CS (93%), and lower

success rate (64%) in those with no history of previous

VBAV after the CS (this is the first VBAC).

DISCUSSION

• The term babies have more chance of successful VBAC,

with the highest success rate was at gestational age

between 39 and 39+6 weeks

• Although it was suspected to have more failure rates with

increase weights of babies, but in our study there was 10

cases included with weights of 3500-4500 , with success

rate of 100% and no reported maternal nor newborns

medical complications in the first month post partum.

DISCUSSION

• Indications of Elective repeat of CS included: Breech

presentations, low laying placenta, placenta previa

centralis, and history of previous 4th degree tear.

Also there were special cases like: Twin IVF, and Singleton

IVF after history of infertility for 17 years.

• Indication of urgent CS (failed VBAC) in the all 6 cases

was Pathological trace, which is commonly termed as

'fetal distress‘

This means : the CTG in labour shows a pathological

abnormalities that may imply possible hypoxia and birth

asphyxia.

DISCUSSION

• The number of reported cases of Uterine rupture during

VBAC trials in our study was ZERO !

On the other hand , Results of Royal collage study showed

that VBAC carries a risk of uterine rupture in 22-74/10,000.

• No reported newborns medical complications nor need for

NICU admition.

• In the first month post partum there was no reported

maternal medical complications.

PLANNED VBAC IN

SPECIAL CIRCUMSTANCES

According to Royal collage study :

• There is similar successful rates of VBAC in twin pregnancies to that in singleton pregnancies.

• Also, there is increased risk of uterine scar rupture for women with a short inter delivery interval (below 12-24 month).

Special case in Our study :

• G3P5A0 (Gave twins twice)

• 2013 CS : Twin

• Jan 2015 VBAC : Singleton

• Nov 2015 VBAC : Twin , with no recorded medical complications in the first month post partum.

LIMITATIONS

• Sample size.

• Lack of prior research studies on this topic in Palestine .

• Lack of detailed data in the medical record of some

patients.

CONCLUSION AND

RECOMMENDATIONS

Through our study we found that VBAC is

undertaken in HGH with a Very good

results, so it should be undertaken in all

Palestinian hospitals.

FUTURE DIRECTIVES

• To improve our study by including a wider sample,

covering longer period of time, and inserting more

variables like: APGAR score of baby and Maternal BMI.

• Spread knowledge about benefits of VBAC and giving

good science based counseling for mothers with previous

1 CS who have to go VBAC.

• Re-audits should be undertaken regularly in other local

hospitals to make comparisons for similar clinical settings

in Palestine.

THANK YOU