Vaginal birth after caesarean section

                Caesarean section or C-section is a surgical procedure used to deliver a baby through an incision made in the mother’s abdomen (laparotomy) and a second incision made in the mother’s uterus (hysterotomy). Meanwhile, vaginal birth after caesarean section or VBAC occurs when a woman having a vaginal delivery when she has had at least one baby by caesarean section previously.

               

                A woman underwent a caesarean section for few reasons. It can be due to maternal indication, or baby indication, or both. Maternal indications that lead to caesarean section include previous history of caesarean section, obstruction of birth canal such as tumor in the birth canal causing delivery to be obstructed, and pelvic abnormalities such as small pelvis. Fetal indications include breech, congenital malformation, compromised fetal condition, and so on.

                Every procedure will have its own complication. Same goes with C-section. Complication that may arise from C-section include infection which can arise from the wound itself or from other source such as urinary tract infection, thromboembolic disease such as deep vein thrombosis, anesthetic complication, injury to adjacent organ of the uterus such as bladder and bowel, uterine atony which the uterus unable to contract well after delivery causing bleeding from the uterus and so on.

                Maternal complications increase with Caesarean delivery relatively compared to a vaginal delivery. Thus VBAC may avoid some of the suitable candidate from encounter complication of C-section. However, not all candidate is suitable for VBAC. This is because there is risk for ‘uterine scar rupture’ for those who opted for VBAC. Therefore, candidates with high risk for uterine scar rupture are not suitable for this option, and they have to proceed with C-section.

                There are few criteria to be considered before making VBAC an option for delivery: 1) One previous low transverse C-section. 2) Clinically adequate pelvis. 3) No other uterine scar / previous uterine scar rupture. 4) A physician immediately available throughout active labor who is capable of monitoring labor and performing an emergency delivery (when indicated). 5) Availability of anesthesia and personnel for emergency C-section.

Ectopic pregnancy

Definition

Risk factor and causes

Types of ectopic pregnancy

Diagnosis

Definition

Ectopic pregnancy can be defined as implantation of fertilized ovum in an area other than the endometrial lining of the uterus.

‘Pregnancy in area other than uterus’

Types of ectopic pregnancy

Ectopic pregnancy is classified based on the location of the ectopic pregnancy.

The most common type is tubal pregnancy (pregnancy in the fallopian tube).

Others include ovarian, abdominal, cervical and corneal.

Risk factors and causes

Different types / location of the ectopic pregnancy may have different risk factors and causes.

For tubal pregnancy (pregnancy in the fallopian tube), the risk factors are:

Pelvic inflammatory disease

Previous tubal surgery

Previous infertility surgery

Utero-tubal anomaly

Endometriosis

Smoking

Exogenous hormone

Diagnosis

There is a triad to describe common presenting symptoms of ectopic pregnancy :

Amenorrhea

Lower abdominal pain

Vaginal spotting

However ,high index of suspicious is very important as ectopic pregnancy can be life-threatening. When a lady in her productive age presented with one of the symptoms, one of differential diagnosis should be ectopic pregnancy.

Other signs and symptoms include shoulder tip pain and cervical motion tenderness.

Placental migration

Low lying placenta and placenta previa

Placental migration

________________________________________________________________________

Low lying placenta

Placenta previa is usually diagnosed after 20 weeks of gestation. This is because about 90% cases of low lying placenta in early pregnancy resolves later in pregnancy. This phenomenon is called placental migration.

________________________________________________________________________ 

Placenta migration

The phenomenon of placental migration occurs when there is change in the position of the placenta with advancing gestational age. There are two hypotheses for this phenomenon:

1)Dynamic placentation- placental attachment points are constantly forming and reforming.

The re-position of the placenta occurs as a response to uterine growth as well as placental growth. As the lower uterine wall forms and the muscle stretch, the stress causes the attachments in this area (lower uterine) to degrade. As those attachments degrade, new attachment points are formed higher in the uterus in areas that is not subjected to the same kind of growth stress, thus the placeta ‘move’ through degradation and re-formation.

2)Trophotropism- placenta migrates to find best blood supply.

As the uterus grows, the lower part of uterine wall get stretched and become thin, causing the blood supply in the area thins. The placenta moves upward to the thicker upper uterine wall to get better blood supply.

Placenta previa

Definition

Types

________________________________________________________________________ 

Definition

Placenta previa is a pregnancy complication in which the placenta is abnormally placed in the lower uterine segment, and covers, partially or completely, the cervix.

________________________________________________________________________ 

Acute compartment syndrome

Definition

Recognizing signs and symptoms

High index of suspicious

________________________________________________________________________ 

Definition

A condition resulting from increasing pressure in a confined body space, especially of the leg or forearm, leading to reduce in blood flow, which prevent nourishment and oxygen from reaching the tissue.

________________________________________________________________________

Recognizing signs and symptoms

The tell-tale sign of acute compartment syndrome is ‘pain disproportionate to the injury’. Look for the 5P’s for condition highly suspicious for acute compartment syndrome.

Pain

Pallor

Pulse

Paraesthesia

Paralysis

**poikilothermia (additional)

 ________________________________________________________________________

High index of suspicious

Acute compartment syndrome is best to be avoided rather than treated. It is a limb-threatening condition, if patient already diagnosed with acute compartment syndrome, most likely its already to late, the limb might not be able to be saved, or become functionless.