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UNSCHEDULED ADMISSIONS AND DELIVERY IN WOMEN WITH PRIOR CAESAREAN BIRTH AND PLANNED FOR DELIVERY BY ELECTIVE CAESAREAN

M Suchetha , R Jameison;  Princess Royal Maternity Hospital ,Glasgow , United Kingdom

References

Timing of elective caesarean section has become increasingly important as more and more women now request caesarean. Benefits of delayed caesarean need to be balanced against risk of spontaneous labour prior to planned date of delivery for women with prior CS.

Although the number of patients in the study was small, a significant number of women delivered between 38 and 39 weeks of gestation [28/60] .Delivering women identified to be in labour sooner may prevent some complications like a difficult second stage caesarean section.

Effort should be taken whenever possible to reduce risks of emergency caesarean in women with prior caesarean. Larger studies can provide more evidence.

Background : Up to 10% women go into labour prior to the scheduled date at 39 weeks. When patients choose elective repeat caesarean section they may expect to avoid maternal as well as fetal complications that can occur during labour .

Results:

60 patients were identified. 82% had one, 13% had two and the rest three previous CS. 15% had a history of a previous vaginal delivery. In 82% CS was planned for 39 weeks of gestation. The rest were planned for CS between 36-38 weeks due to other complications of their pregnancy.

Reasons for admission :Majority [47%] needed admission at 38 weeks. 48% presented with symptoms of labour , 17% with symptoms of PROM, and others with APH[5%], decreased fetal movements[1/60] , and monitoring for medical complications [6.6%] . Management on admission:Most women were seen by medical staff within 45 minutes of admission. 28% were diagnosed to be in labour at admission. From triage 28% were admitted to labour ward, 67% to the maternity ward and one went straight to theatre. 40% went into labour whilst being observed as inpatients and another 18% showed evidence of fetal distress. 30% were delivered within 6 hours of admission. Urgency of CS was category one in 5% and category 2 in 35% .

Aims : To Identify the reasons for unscheduled admissions , whether these women were promptly seen and managed , whether they experienced any complications , and their mode of delivery.

Place of study : Maternity unit, Princess Royal Maternity Hospital Glasgow

Study design : Retrospective analysis of case notes

Study period : 12months starting from 1st December 2009– 31st November 2010

Methods :All patients who were booked for elective caesarean but were admitted and delivered prior to the planned date were identified from the booking folder kept in the Labour Ward and the Operations Register kept in the maternity theatre . Also a list was generated from PROTOS , the computerised data system of patients who were scheduled for CS category 4 but delivered by category 1-3. Case notes were collected with the help of medical records department in our hospital.

Theatre 1

Labour ward 17

Antenatal ward 40

Table 6: Admission after triage

Evidence of labour 24

Fetal distress 11

Raised Blood pressure 1

Antepartum haemorrhage 3

Table 7: Concerns while in patients in the ward

SVD1-CS1-SVD1 1  

SVD1-CS3 1 CS1-SVD1 1SVD1-CS1 2 CS1-FD1 1FD1-CS1 2  

CS1-VD1-CS1 1  

Table 2: Number of previous vaginal & caesarean deliveries

SVD –spontaneous vaginal delivery FD –forceps delivery CS -caesarean

< 6hours 18

6-12 hours 7

13-24 hours 4

24-48 hours 3

2 days 2

4 days 1

Table 8: Interval between admission and delivery

Table 11: Decision delivery interval in caesareans

Ventouse 3

Midcavity forceps 3

Keilland’s rotational forceps 1

Preterm spontaneous vaginal 1

Caesarean 52

Table 9: Mode of delivery Leaking fluid vaginally 10 [6preterm]

Contractions 29 [5 preterm]

APH 3

Decreased fetal movement 1

Muscle pain , epigastric pain 1

others 4*

Table 3: Presenting complaint

*elective admissions for medical conditions like pre-eclampsia, diabetes, oligohydramnios ,or for steroids but needed early delivery due to spontaneous labour or suspected fetal distress prior to the scheduled date/time

No evidence of labour 10

Active labour 2

Early labour 9

SROM, early labour 3 [breech-1]

SROM 9[meconium-2, preterm-3]]

Preterm labour 3

APH 3 [placenta praevia-1 , abruption-1]

Muscle pain, gastritis 1

others 4* [as above]

Table 4: Diagnosis

1 1

2 21

3 10

Not recorded 19

Table 10: Urgency of caesarean

<30 min 2

30-60 min 9

60-90 min 2

90-120 min 2

3 hours 1

4 hours 1

5 hours 1

Those who had vaginal delivery did not want VBAC earlier but changed when labour progressed especially when found to be in 2nd stage.

Scar dehiscence 3* [1 was complete , baby’s face presenting at laparotomy]

Hole in lower segment 1

Longitudinal tear lower segment

2

Angle extension 1

Major blood loss 3 [ 1 abruption –ITU]

Acute stress disorder/?psychotic

1

Poor Apgars 3

Thick meconium 2

Special care baby unit 5 [2 preterm]

One patient who was an in patient overnight was found to be fully dilated during a routine preoperative ward round by the elective caesarean registrar. There was one stillbirth which was due to severe antepartum haemorrhage and abruption in a previous two caesarean patient inspite of urgent caesarean. There were no other adverse outcomes to babies related to delivery. Many of the patients were inpatients for several hours and had to be delivered overnight due to various concerns. Consultants were called in for the major complications.

Table 12: Complications

Conclusion

Acknowledgements : Dr Phil Owen , M Leonard , B Sutherland

Birth after caesarean section , Feb 2007 ; RCOG Green top guideline.

1st previous CS Failure to progress in labour 19[6-2nd stage]

Fetal distress 12abruption 2PET & eclampsia 5breech 4IUGR 4Placenta praevia 2PPROM 1

2nd previous CS PPROM 1Placenta praevia 1Previous CS 4NR 2

Table 1: Indications for previous caesareans

39 8

38 28

37 9

36 9

34 3

33 1

31 1

28 1

Table 5: Gestational age in weeks at presentation

APH - antepartum haemorrhage

SROM – spontaneous rupture of membranes