LEGALLY SPEAKING
Risk management in obstetrics and gynecology

Any trial of labor after prior cesarean delivery increases risks and concerns, even under the most routine circumstances in the most controlled environment. Unknowns about a patient's previous delivery history and factors that arise during the course of a VBAC attempt can further complicate the situation. When that happens, it's imperative that every decision a clinician makes along the road to delivery be informed by the elevated risk of rupture.

CASE STUDY: WHEN NOT TO ATTEMPT VBAC

By Andrew I. Kaplan, Esq.

THE FACTS

The patient, 27 years old and in her 40th week of pregnancy, was admitted to the defendant hospital's Labor and Delivery Floor at approximately 4:15 pm on November 1st, after presenting to her prenatal clinic, where she was diagnosed with oligohydramnios. She had last given birth in 1997, in the Dominican Republic, via cesarean because of a breech presentation. The type of incision performed was undocumented.

At 7 pm on 11/1/2000, the patient was 1 cm dilated and 25% effaced. At 9:10 pm, she was 3 cm dilated, 70% effaced, and the fetus was at –1 station. At approximately 9:30 pm, induction with oxytocin was started. By 1 am, the patient's contractions were described as progressing from mild to moderate; by 1:10 am, they were occurring every 4 to 5 minutes. At 1:30 a.m. the fetal heart rate was in the 150s with adequate variability, and contractions were occurring every 3 to 4 minutes. The patient's cervix was 4 cm dilated and 80% effaced.

At 1:35 am the oxytocin was discontinued and epidural anesthesia administered. Twenty minutes later, the oxytocin was resumed at 4 mIU. At 3:30 am the patient was contracting every 2 to 5 minutes, with occasional decelerations, and the oxytocin was being administered at 7 mIU. By 5 am, the patient's cervix was 5 cm dilated and 100% effaced, and a deceleration to 70 bpm occurred, at which time the fellow, Dr. P, turned the patient on her left side and administered oxygen. At that time, the oxytocin infusion was at 6 mIU. At 5:40 am the nurse-midwife reported that contractions were difficult to pick up on the monitor. The patient's cervix was now 9 cm dilated and the fetus was at 0 station. The nurse-midwife's notation indicated that the physicians still anticipated a spontaneous vaginal delivery.

At 6:15 am, two decelerations to 90 bpm were documented, lasting 40 seconds. At 6:23 am, two additional decelerations to 60 bpm were documented, and the patient was contracting every 3 minutes. At 6:40 am, there was another documented deceleration to 80 bpm for 10 seconds, and at 6:50 am, the epidural was turned off and the patient was encouraged to push. The FHR baseline was 145 bpm, with adequate variability. At 6:55 am, an additional deceleration to 50 bpm for 20 seconds was documented.

At approximately 7:10 am, the nurse-midwife asked Dr. P to evaluate the patient because they were having "difficulties" with the internal monitor. Dr. P noted that the FHR was in the 50 to 60 bpm range and then attempted to replace the internal clip. After multiple "failed" attempts, Dr. P ordered placement of an external monitor. At 7:18 am, after placement of the external monitor, the FHR was noted to be in the 110 to 120 bpm range, with decelerations down to 50 to 60. At 7:20 am, the maternal pulse was 127 bpm, the FHR was 60 to 70 bpm, and uterine contractions were untraceable. At 7:25 am, the maternal pulse was 121 bpm, FHR was between 120 and 130, and the patient was advised that if the FHR decreased again, she would be taken for cesarean delivery. At 7:27 am, the maternal pulse was 127 bpm and the FHR was 120 to 130 bpm, with positive accelerations to 140, but uterine contractions were untraceable.