Vaginal Birth After Caesarean - Thesis Example

Introduction: Vaginal delivery of a baby after a previous caesarean section is called vaginal birth after caesarean (VBAC). When a patient agrees to go for a vaginal delivery after a previous c section it is referred to as a "trial of labour." It simply means that the patient plans to go into labour with the intention of having a vaginal delivery. But as in any labour it is not a sure shot thing .As many as 4 out of 10 women who have a trial of labour need to have a c section. Patient Preference Those patients who opt for VBAC generally have gathered a lot of information about the risks involved and the facts relating to it. Hence it is the amount of data that they have gathered and the facts themselves that influence their thinking. Many are of the opinion that VBAC trial of labour can be thought of only when there has been one low side to side scar c section , or in case of more than one caesarean but also accompanied by previous vaginal delivery. All in all many patients think that VBAC is safe after the age of 35, or when the foetus is big or that the pregnancy has progressed more than 40 weeks, yet it remains again to doubt as these facts themselves lower the chances of being able to deliver vaginally. But still patients having acquired this kind of data prefer VBAC and this stems from basically the intrinsic desire to be able to experience the natural process of birth and plus avoidance of the scar that the c section leaves behind and the post operative pain . Importance of Information: All those who opted for VBAC knew that Information gathering was very important as it helped them to cope with the situation in a better manner and to understand the risks involved and eventually make a better judgment for themselves. Preparing for VBAC: Preparing for the VBAC included assessment tests. This basically covered the health and history of the patient , The preference of the doctor present at the time of birth. The hospital itself, etc and lastly the teamwork involved in making the whole procedure successful. Worry and Fears of Patients Regarding VBAC: Patients had fears about VBAC and this stemmed basically because of the following reasons They wanted a speedy delivery They did not want to experience any pain during the delivery process. They had previously failed the normal process of vaginal birth. They did not want to experiment with the rare risk of the c section scar opening up during the vaginal delivery and fearing of which shrunk these patients from considering VBAC. The fact that a prior scar could open and it is very dangerous for both mother and baby put the patient's nerves at edge, for in such emotional status it was too worrisome for them to consider anything remotely dangerous for their babies, and did not want to take any risks. Most patients who had doubts about the hospital facility of handling emergency shrunk from the risk, and especially patients who's labour did not start on its own and cervix remained closed and firm. Patients having vertical uterine c sections avoided it totally .Those with multiple caesareans, single layer closures, uterine surgery, narrow pelvis, breech foetus, triplets, genital herpes also could not have VBAC. Anxiety of patients regarding Caesarean: Infection that could develop, in the incision. Blood clots Breathing problems, this in case of miscalculated date of delivery and the baby lungs not developed fully. Foetal injury. Scaring, after the operation. Pain. The patients were not all that hype about being under the affect of anaesthesia. Excessive blood loss. Facts the patients felt most concerned about and questioned about 1. A caesarean section is a surgical procedure and requires the use of anaesthesia. Any surgery carries a risk of infection, excessive blood loss, and problems caused by the anaesthesia. 2. Women who need a caesarean after a VBAC trial of labour have a higher rate of infection than those who have a caesarean without a VBAC trial of labor.1 3. Whether your doctor will be available in the hospital throughout your labour and whether the hospital has facilities for an emergency caesarean delivery. 4. The possibility that a trial of labour may end in caesarean delivery. 5. How and at what point during labour the decision is made to do a repeat caesarean. 6. Which types of pain medicine or anaesthesia you may use during labour and delivery or a caesarean. 7. Any particular risk factors for uterine rupture during VBAC and the possible complications of a rupture, such as removal of the uterus (hysterectomy). A. Preference of Family Physician vs. Obstetrician This varied a lot in women and mostly depended upon how satisfied they felt with their decisions in choosing VBAC or how confident they felt about the staff and the doctor of the hospital they listed themselves in. B. VBAC PATIENTS Preferred FAMILY PHYSICIAN: The patients who chose to go ahead with VBAC preferred to have the family physician present at the time of the process. The ratio was 60 % who solely depended upon their family physician to carry out the procedure and there were 10 % those who wanted their family physicians to be present at the time the obstetrician performed the delivery process. The rest of the 30% wanted the obstetrician to perform their delivery, and this was usually true in patients who were confident of their health and of the hospital they had chosen. Many of the patients decided for the family physician for the following reasons They felt comfortable having someone around them at the time that knew them on a personal level and could better understand their need and provide comfort at the same time. They felt more confident in having someone they had known for many years and could relate better with them with any psychological distress they might feel. They were able to have a more close understanding with the family physicians and found it to be quite natural and easy to answer their questions or ask any of their own. It gave them a feeling of comfort to have someone around whom they had trusted with previous ailments over the years. Many of the patients chose their family physicians as in their prior delivery with an obstetrician involved they had failed to give birth naturally and it was just a lack of confidence and fear that they opted having their family physicians around. C: Statistics: Statistically it is now seen that having a female support person at the time of giving birth to provide continuous emotional support has been shown to have dramatic effects. Studies have shown that the women who received continuous support of this kind had significantly better outcomes compared to women who did not have such a support. The rate of caesarean delivery was 8 % in the group who received support compared to the 18 % who did not have any. D: Convincing Factors for VBAC patients: The VBAC patients felt confident with the knowledge that after having a prior caesarean they could still opt for the normal delivery, and that too they felt at ease in knowing that it was their option in choosing the doctor and the whole environment in which they could proceed with the delivery. Having all the information at hand and the facts about their situation and what possibilities were available they felt quite at ease in deciding for VBAC and much of their psychological anxiety was diminished Result All in all the obstetric practice that follows the philosophy of fostering maximum involvement of patients in decisions regarding their care and maximum involvement of their support structure in the labour process appears to be a practice that leads to safer, shorter, and a much more satisfying birthing experience. CESARIAN PATIENTS: Patients who opted for caesarean section also opted for the family physician being 80 %.These patients had less anxiety and felt comfortable having someone around them that they felt comfortable the rest of the 20 % went along with the doctor that was available at the hospital they chose as they felt confident with the environments A. Anxiety of Patients regarding VBAC: An unsuccessful trial of labour leading to caesarean, stalled labour or foetal distress were the common highlighting factors, this eventually increased the risk infection of both mother and baby. Slight separation of an existing caesarean scar called dehiscence, although this is not harmful yet the possibility caused alarm in quite a few patients. Uterine rupture which could be fatal for both mother and baby. If rupture cannot be repaired quickly it could lead to removal of uterus called hysterectomy to prevent severe blood loss. B. Patient preference in regard to Benefits of VBAC : Many of the patients found that there were many benefits associated with the decision of VBAC. These being Avoiding scar on uterus. Less pain after delivery. Fewer days in the hospital and speedy recovery at home. A more active role in bringing up the child. Low cost Greater participation in birth Lower risks of blood loss These factors plus the psychological association while feeding the baby proved to be the most essential factors in opting for the VBAC. C. Encouraging Factors: Those patients who had undergone a prior c section knew how difficult breast feeding had become for them because of the stitches and they could not hold the baby for longer periods of time against them, and more than ever wanted to feel the closeness as well as the satisfaction of breastfeeding their baby. Many of the patients found it very easy to go along with VBAC happily as their health was good and so was the progress of their baby. D. Positive Aspects: Moreover they felt more confident with the knowledge that the size of their babies was normal and that they were in vertex position. In addition they saw little cause of worry when their labour started on its own and progressed well with well dilating cervix. Many of the patients felt confident going ahead with VBAC by having their family physician present plus with a hospital that could handle an emergency c section if anything went wrong. EXAMS AND TESTS: Besides the prenatal tests the doctor ensures other additional measures for the VBAC to be normal for the patient. For the process to be safe this may include: A review of the surgery records to verify the type of the incision used for the previous incision. A foetal ultrasound Foetal heart monitoring which is also used during labour and delivery to watch for foetal distress. Benefits of a successful VBAC include: Avoidance of another incision in the uterus thus eliminating risks by avoiding future scars as each additional scar in the uterus raises the risk of placenta problems in later pregnancies such as placenta previa, or placenta accrete. These further raise problems of fetal risk and hysterectomy Hypothesis: I expect a mixed response to this question. Some patient will prefer their family doctor because of the fact that patient has long term relationship with their family physician and receive the prenatal care from the family physician and will feel comfortable having them to attend the VBAC. But I also hypothesis that a group of patient will prefer to have their obstetrician to attend the delivery because of the fact that they feel obstetricians has more specialized training in this area. I also hypothesis that patient will have specific fear and anxiety related to VBAC and if we can address that fear as a family physician we would be more successful to ensure success in VBAC. Importance of this study: This study will provide the clear idea about what are the patients worry/fear in regards to going for the VBAC and whether they will be comfortable having their Family Doctor attending the delivery or they are more comfortable their obstetrician to attend the delivery. This study will provide ample information about what VBAC is and the risks if any to both mother and the baby and in future help both doctors and the patients in feeling confident with the knowledge gathered to be able to make decisions regarding delivery process. Benefits Of this study Finding of this study will enable the family physician to counsel the patient accordingly and ensure better care to the VBAC candidate. Study shows that woman who are well informed regarding VBAC and have good support from the family doctor have better outcome with the VBAC. If the result shows most of the patient chooses their family doctor to attend VBAC we can ensure family physician residents receive more training during the residency. Continuing Medical education (CME) can be offered to gather more knowledge towards VBAC. If the result shows most of the patient prefers their obstetrician to attend the delivery and if we know why what is the worry/fear we can address that issue during the prenatal visit with the family doctor to ensure that patient feels comfortable to have their family doctor to attend the delivery. Method Involved: A questionnaire will be prepared to assess the current acceptance of VBAC by patients in urban setting who have had a single prior Caesarean birth. Questions will include demographic details, statements regarding the safety of VBAC, issues of fear and anxiety related to VBAC and their preference of family doctor or obstetrician to attend the delivery. There were thorough questions that covered almost all the aspects regarding the options available to patients undergoing VBAC plus all the necessary information that could help in easing their anxiety. The method targeted questions that addressed the patient's fears. Obtaining the preference of patients for choosing their own family physician, or the obstetrician to be present at the time of delivery. Explaining induction of labour, of patients having a previous uterine scar. Study Design: The study was designed in a way to help in the future both the doctors and the patients. Ample VBAC Education was provided detailing the process its precautions and enlisting the medicine involved. For them to better understand the importance and complications of VBAC and in future to handle it in a better and in a successful way. For this the study provided detailed knowledge, facts and statistics along with a rigorous questionnaire to help understand the patient's anxiety and acknowledge their fears. A. Sample Size: A total of 100 surveys will be distributed, with an expectation of 50 responses at least. B. Data Collection: This was done through questionnaires prepared for the survey. C. Reliability and Validity: Question will be provided with an addressed, postage paid envelope to 100 pregnant patients with an expectation of 60 percent successful responder. Upon receipt of the completed survey, results will be entered into a database for subsequent analysis involving frequency distributions D. Ethical Consideration: Consent of the patient will be taken and the information will be kept anonymous Appendix: A. Questionnaire: What are some of the tips that I can use to reduce my risk of having repeat caesarean If I go for VBAC what can I do to increase the likelihood of giving birth vaginally Are there any practices used in VBAC that one needs to avoid What are the steps required to be taken when one opts for either VBAC or Caesarean Any tips in helping the scar of uterus during VBAC How to find a hospital that will support my wish for VBAC How can I be helped with unresolved emotional issues What are the tips of having a safe delivery in a repeat caesarean How can one have a satisfying caesarean birth experience What are the concerns regarding risks of c-section compared with vaginal birth or vice versa What is the likelihood of scar rupture during VBAC What is the likelihood of hysterectomy in case of VBAC What are the disadvantages of having multiple uterine scars on future pregnancies B. Explanation of Study: Most obstetricians indicated VBAC to be the safest option for the woman, but were less certain about benefits and risks for the infant. The consensus of practice is to present VBAC as an option and induce labour if needed. Vaginal birth after Caesarean is preferred in a level two or three hospital, with an anaesthetist, neonatologist and operating theatre available within 30 min C. Consent form : A consent form would be provided for use of the information gathered in the survey to be used, while anonymity guaranteed. References: 1. Lydon-Rochelle M, et al. (2001). Risk of uterine rupture during labour among women with a prior caesarean delivery. New England Journal of Medicine, 345(1): 3-8. 2. Par E, et al. (2005). Vaginal birth after caesarean section versus elective repeat caesarean section: Assessment of maternal downstream health outcomes. British Journal of Obstetrics and Gynaecology, 113(1): 75-85. 3. Caughey AB, et al. (1999). Rate of uterine rupture during a trial of labour in women with one or two prior caesarean deliveries. American Journal of Obstetrics and Gynaecology, 181(4): 872-876 4. Mozurkewich EL, Hutton EK (2000). Elective repeat caesarean delivery versus trial of labour: A meta-analysis of the literature from 1989 to 1999. American Journal of Obstetrics and Gynaecology, 183(5): 1187-1197. 5. American College of Obstetricians and Gynaecologists (2004). Vaginal birth after previous caesarean delivery. ACOG Practice Bulletin No. 54. Obstetrics and Genecology, 104(1): 203-212. 6. Bujold E, et al. (2004). Trial of labour in patients with a previous caesarean section: Does maternal age influence the outcome American Journal of Obstetrics and Genecology, 190(4): 1113-1118 7. Bujold E, et al. (2002). The impact of single-layer or double-layer closure on uterine rupture. American Journal of Obstetrics and Genecology, 186(6): 1326-1330. 8. Bujold E, et al. (2002). Inter delivery interval and uterine rupture. American Journal of Obstetrics and Genecology, 187(5): 1199-1202. 9. Cunningham FG, et al. (2005). Prior caesarean delivery. Williams Obstetrics, 22nd ed., pp. 607-617. New York: McGraw-Hill. 10. Guise J-M, Berlin M, McDonagh M, Osterweil P, Chan B, Helfand M. Safety of vaginal birth after caesarean: a systematic review. Obstet Gynecol 2004. 11. Guise J-M, McDonagh MS, Osterweil P, Nygren P, Chan BKS, Helfand M. Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section 12. Hashima JN, Eden KB, Osterweil P, Nygren P, Guise J-M. Predicting vaginal birth after caesarean delivery: a review of prognostic factors and screening tools. Am J Obstet Gynecol 2004 13. Lieberman E. Risk factors for uterine rupture during a trial of labour after caesarean. Clin Obstet Gynecol 2001 Read More