Trial of labour or elective section….what to choose?

I help to provide a low risk obstetric service in a remote area. I work in private practice and provide my services to the local hospital on a fee for service basis.

Imagine a 36-year-old woman who has had four babies by vaginal delivery in another location without any complications.  Her last was an elective section for a breech presentation in a teaching hospital. It was a routine delivery.

Now she comes and asks me where she could have her next baby. If she wants a repeat section would be prepared to do it at our local hospital.

Significant obstetric risks for her include;

  • 1:4 to 1:10 risk of placenta accreta if she has placenta previa
  • 3:100 risk of placenta accreta if there is even if there no placenta previa
  • 3:100 that the next baby also being breech at term

In choosing the mode of delivery the NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights published in 2010 provides some guidance in making this decision. In a hypothetical group of 100,000 women of any gestational age who undergo either procedure the table below shows the complication risks

Trial of labour after a Caesarean section

Elective repeat Caesarean section,

Maternal deaths

4

13

Uterine rupture at term

778

22

Hysterectomy

157

280

Blood transfusion

1200

900

Deep vein thrombosis

40

100

Perinatal deaths

130

50

Neonatal birth trauma

180

30

Neonatal hypoxic ischemic encephalopathy

46

0

The rates of maternal hysterectomy, haemorrhage, and transfusions did not differ significantly between trial of labour and elective repeat Caesarean delivery. I wonder how many GP obstetricians are able to manage the 0.28% of women who will need a hysterectomy?

Currently our hospital only provides elective repeat Cesarean section. This was a decision which predates my arrival and primarily it was a decision based upon the concern that a uterine rupture may overwhelm local resources. Thus the decision becomes complicated by whether the woman wants to go to town or stay home. Generally, the journey to town to await the onset of labour is recommended at around 37 weeks. This is a long time to be potentially apart from support networks and can be a financial drain on families.

Now, something to stir a conversation.

In private practice you can often make a decision not to look after a patient. After all, they may well be seeing you by a quirk of the appointment system. You skill set may not be appropriate to the patients needs. Obviously if the patient has anaemia and melena they need someone who can do an gastroscopy and sort out the bleeding. If they have paranoid schizophrenia they need the help of a psychiatrist.

What if you feel like you have failed engaged with this theoretical pregnant patient and not been able to establish a therapeutic relationship. You can, I believe, suggest that they would be better served by seeing a colleague. But what do you do in a remote setting were the alternative to you providing care may involve a distant journey?

Or do you suck up your reservations and continue to treat her despite your feelings.

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3 thoughts on “Trial of labour or elective section….what to choose?

  1. So what are you asking? Surely you need not do anything except be polite and professional, lay down the options, explain the pros and cons and let her choose. Choose whether to keep seeing you, or give you an earful, bitch about you to everybody who’ll listen, and travel interstate to have the baby with a real doctor. Choose whether to take the low risk option available here with bonus sea views but bad hospital casseroles, or go somewhere else where they have anaesthetists a-plenty and baguettes with brie.
    I tried and failed at a v-bac 2nd time, and you sent me off for the baguette option for my third. It would have been nice not to have to travel but all worked fine and I’m still talking to you. And the baguettes were lovely. Fundamentally, connecting with the patient is optional; some people just don’t connect with doctors who tell the truth.

    • Thanks Ant.

      Free Open Access Meducation does mean that everyone can read blogs. I had hoped that I would get a bit of feedback from fellow doctors about the suppression of humanity when caring for fellow human beings.

      I understand that if a drunken yob spits blood in you face in ED then you should restrain the urge to respond with a right hook. But life throws many more subtle challenges where you have to detach the emotions.

      Still waiting for a comment from a colleague.

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