Wolfgang Henrich

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Coverage of the 2009 World Congress of Perinatal Medicine

Life Threatening Hemorrhages Due to Invasive Placental Implantation

: I am Roberta Speyer and I am reporting for OBGYN.net from the 		  World Congress on Perinatal Medicine in Berlin, Germany. I am speaking with Professor 		  Wolfgang Henrich and we are going to discuss VBAC, vaginal birth

 after cesarean, 	    a very hotly debated topic.

I have a question for you. What about VBAC, vaginal birth after cesarean? We 		  hear a lot of controversy; it is a good idea, it is a terrible idea, do you have 		  an opinion on that?

: This is a very, very, very difficult question. First 		  thing of all if you go to the literature you can see that after a C-section, 		  overall you have a success rate of 75 percent to have the next baby

 vaginally. 		  But if you go in the sub-population and in the analysis you can see that there 		  are different positive factors and negative factors. For instance, the positive 		  factors, if you had already had a vaginal birth before the C-section or after 		  the C-section a vaginal birth, then in the next pregnancy you have a high chance, 		  about 90 percent, to deliver without complications. On the other hand, if you 		  had a protracted labor or failure of progress as a reason for the C-section, 		  then in the subsequent pregnancy you will have only a maximum chance of 50 percent.

So, there are other, further reasons to successful prognostic factors, for instance 		  if you have a spontaneous onset of labor with a physiological effacement of the 		  cervix, then also your chance is increased. On the other hand if the baby is 		  not more than 4.0 kg, so this macrosomia baby they have a bad chance to get delivered 		  vaginally after a C-section.

You have to look into it in detail to predict the individual chance for a successful 		  vaginal delivery after C-section.

Again, we have another option to try to predict a little bit the risk of one 		  major factor, uterine rupture. Uterine rupture in most cases can be a catastrophe 		  for mother and child. The child can be hypoxemic during the uterine rupture, 		  and the mother can lose the uterus for instance, or could come into a life threatening 		  hemorrhage situation. What is the basic risk of the uterine rupture? If you have 		  never been operated on before it is only one in 17,000, it is really a rare event. 		  But if you had a C-section before, you have a risk; it seems to be about 0.2 		  to 0.5 up to 1.5. This is a number. I mean from 100 patients 1.5 will have a 		  uterine rupture with a catastrophe. I don’t know if you would get on an 		  airplane if somebody would tell you at 1.5 percent this airplane will crash.

: You would not go. It depends very much on your counseling 		  in the situation with the pregnant lady. What you say, and if you pronounce this 		  number of 1.5 uterine ruptures, most of them will say, “No, I never want 		  to try that because it is much too dangerous”.

But we might have another option to clarify a little bit more the individual 		  risk. This is again perhaps by ultrasound, because with experience, good equipment, 		  and good transducers you can identify by ultrasound the myometrial layer in the 		  area of the previous C-section. It is proven in only a few studies, but there 		  exist some studies, which show that if you have an extremely thin layer, perhaps 		  less than 1.5 mm, perhaps less than 1.0 mm, you will have an increasing risk 		  of rupture in that patient.

There is still an open debate about the thinning, where is the cut off and does 		  a scar behave the same like original tissue and so on, and what is the force 		  you need to rupture a layer of 1.0 mm and so on. Studies showed, and my own experience 		  showed, you are even able to detect windows of the uterine scar, a daily senses 		  of the uterine scar. We have several cases where we look in advance before the 		  try of vaginal birth after C-section, and we look to the lower uterine segment 		  for 36/37 weeks. When we see a daily sense, or window, we do not recommend to 		  go under spontaneous delivery because the risk needs to be higher than if you 		  have a stable wall about 2.0, 3.0, or 4.0 mm.

Again, we have bad news, the increasing rate increases the rates of uterine 		  rupture during vaginal birth after C-section; on the other hand we might have 		  the chance with ultrasound to try to find an individual risk for this situation. 		  You also look to the biometry of the baby. You can estimate the weight of the 		  baby. You can look to the cervical length if you have an effacement of the cervix 		  already. It is very important to counsel these patients individually to find 		  the right way to deliver them.

: I think that is very interesting and very helpful. Vaginal birth 		  after cesarean, I would sum up as saying, it has risks, it may be right for some 		  patients, may not be right for others. If you use the tools, the ultrasound that 		  is available you can make that determination working with the patient. They can 		  be aware of their risks and you can also look at the end and make the decision 		  as far as how to go.

: Again, for this topic, the decision for the first 		  C-section has to take into account the further family planning.

Author | Wolfgang Henrich

Articles

Life Threatening Hemorrhages Due to Invasive Placental Implantation

Vaginal Birth After Cesarean VBAC; Good idea or bad idea?