Amt. N Z J ObArrt G\naetol 1996; 36: 4: 417

Induction of Labour for Trial of Vaginal Birth After Caesarean Section in a Remote District Hospital

Sailesh Kumar', MMed (0 and G), FRCS (Ed), MRCOG, MRACOG and Panos Maouris:, MD, MRCOG, FRACOG

Port Hedland Regional Hospital, Western Australia

EDfTORIAL COMMENT: We accepted this paper because it expresses an obstetric philosophy evolved in the circumstance of obstetrics practice in a hospital 1,800 km from a State capital city with patients whose homes may be hundreds of km from the 'local' hospital. In this setting induction of labour is more than a social convenience. This paper explores the hypothesis that it is reasonable to practise this finesse even when the woman has had a Caesarean section and wishes to achieve a vaginal delivery. This series is, as the authors indicate, very small - absence of perinatal mortality or uterine rupture in 33 cases of trial of vaginal delivery after Caesarean section, with induction of labour in 26 of them, does not prove that the procedure is safe even if the obstetrician has the experience necessary to pe8or-m Caesarean hysterectomy should uterine rupture occu): Targett (A) reviewed a series of 1.577 patients having trial of vaginal delivery after Caesarean section and reported an incidence of uterine rupture of 0.8%. He concluded that to ensure the greatest chance of vaginal delivery with optimum safety, the onset of labour should be spontaneous. It is against this background that the excellent results in this small special series from Port Hedland should be viewed. Our statistician commented that with 33 cases and given a 0.8% chance of scar rupture, the study would have a 77% probability offinding no cases of uterine rupture just by chance. However; it does say with 80% certainty that the rupture rate is not more than 5%! The takeaway message from this report seems to be that induction of labour was favoured, not to increase the success rate of vaginal delivery afer Caesarean section, but to satisfy the problems of planning the time of delivery within hours in women who had a previous Caesarean section and were living remote from a hospital with staff not routinely available to monitor labour and deal with any complications.

(A) Targett C. Caesarean Section and Trial of Scar. Aust NZ J Obstet Gynaecol 1988; 28: 249-262.

Summary: In a retrospective review of 79 women with 1 or more previous caesarean section, 33 (41.8%) women agreed to a trial of vaginal birth. Twenty nine women had labour induced and 26 (89.7%) of them had a suece~~fd vaginal delivery. Four women laboured spontaneously and 1 of them needed an emergency Caesarean section for failure to progress. The overall vaginal delivery rate for women selected to undergo a trial of vaginal birth after Caesarean was 87.9%. The overall emergency Caesarean section rate was 4 of 33 (12.1%). During the study period the Caesarean section rate for the hospital fell from 32.2% to 11%. This study suggests that induction of labour in women with a previous Caesarean section is very successful in achieving vaginal delivery and has a role to play in remote and rural hospitals.

1 . Senior Registrar in Obstetrics and Gynaecology. 2. Specialist Obstetrician and Gynaecologist. Address for correspondence: Dr Sailesh Kumar, King Edward Memorial Hospital, 374 Bagot Road, Subiaco 6008. Perth, Western Australia.

418 AUST. AND N.Z. JOURNAL OF OBSTETRICS AND GYNAECOLGGY

Fort HedIand is a coastal town situated approxi- mately 1,800 km from Perth in the North West (Pilbara) region of Western Australia. It is pre- dominantly a mining region with a population of about 13,000 people. Port Hedland Regional Hospital (PHRH) is the main hospital for the Pilbara region and provides acute medical services in most specialities. There is a specialist obstetrician and gynaecologist as well as a general surgeon. In addition there is also an anaesthetic and a paediatric registrar, and from January, 1996 an obstetric registrar seconded from the teaching hospitals in Ferth. There are approximately 380 women delivering in the hospital each year.

In February, 1994 a new specialist obstetrician was appointed to take over maternity services in the hospital following the resignation of the previous specialist. In an effort to reduce the Caesarean section rate which had previously been more than 30%, a policy of offering a trial of vaginal birth after Caesarean section (VBAC) to all women with 1 previous Caesarean section was instituted. This was later modified to include selected women with more than 1 previous Caesarean section an opportunity of VBAC.

It is widely accepted that a woman with a previous Caesarean section has the best chance of achieving a vaginal delivery when she starts in labour spontaneously. However in PHRH there were a number of special reasons making induction of labour (IOL) a better option in these patients. The specialist obstetrician, although based in Port Hedland, also visits outlying towns and hence is not always physically present in Port Hedland. The District Medical Officers (DMO) who shared the obstetrics workload with the specialist obstetrician did not have sufficient experience in managing trials of VBAC. These patients were therefore offered induction of labour between 38-40 weeks’gestation on a day when the specialist was in the hospital. The geography of the Pilbara region of Western Australia is such that some patients needed to travel considerable distances for medical care. These patients were not willing to leave their homes hundreds of kilometres away and come to Port Hedland to await the onset of labour, but were prepared to do so if an elective induction of labour was offered. Rather than have patients with a previous Caesarean section labour spontaneously and then be transferred to hospital, an elective admission and subsequent IOL appeared to be the better alternative. In addition, the majority of theatre staff lived about a 20-minute drive from the hospital and were not resident in the hospital out of hours. By inducing labour early in the day it was hoped that the majority of women would deliver during office hours thus increasing the safety of the trial for VBAC.

The purpose of this study was to audit the change in practice following the change in obstetrician at Port Hedland Hospital. It is a retrospective review of the success rate of VBAC in this hospital given a high rate of induction of labour.

PATIENTS AND METHODS During the period from June, 1994 to March, 1996

(22 months) there was a total of 678 deliveries at Fort Hedland Regional Hospital. Seventy nine women were identified from the labour ward Birth Register as having one or more previous Caesarean sections. Forty five women had just 1 previous Caesarean section. The medical records of all the 79 women were reviewed and data on the previous pregnancies as well as the current pregnancy and labour were collected.

Thirty three of the 79 women (41.8%) agreed to undergo a trial of VBAC. Of these 33 women, 30 had I previous Caesarean section and the remaining 3 had had 2 previous Caesarean sections. Four women (1 2.1 %) went into spontaneous labour before the time of planned induction. Twenty nine women (87.9%) had labour induced.

h v i d e d that the cervix admitted at least one finger, artificial rupture of the membranes (ARM) was per- formed using the Amnicot finger glove (Go Medical Industries, W. Australia) and an oxytocin infusion was started at the time of the amniotomy. Twenty six women had labour induced by ARM and an oxytocin infusion (5 Units in 500 mL of 5% glucose solution), starting at 40 mt/hour and increasing every 15 minutes to a maximum of 120 mUhr. Only 3 women were given prostaglandin gel initially to improve the favourability of the cervix prior to rupturing the membranes. All the women who were induced had their membranes ruptured between 7.30 and 8.00 am.

All the labours were monitored by continuous cardiotocography. Fifteen women (45.596) received epidural analgesia and the rest used either nitrous oxide or intramuscular pethidine or both.

An emergency Caesarean section was performed if there was objective evidence of fetal distress. confirmed with fetal blood sampling or failure to progress in labour despite good contractions.

RESULTS Forty six (58.2%) of the 79 women with one or

more previous Caesarean section underwent an elective repeat Caesarean section for various reasons including patient request. Of these women, IS had only 1 previous caesarean section but were either not keen on attempting a trial of VBAC or were judged to be unsuitable to do so. The remaining 33 women (41.8%) chose to have a trial of VBAC. and the

SAILESH KUMAR AND PANOS MAOURIS 419

majority were therefore given a date for induction of labour. Of the 29 women who had labour induced, 26 (89.7%) had a successful vaginal delivery. Three of the 29 women (10.3%) had emergency Caesarean section for failure to progress in labour, 1 of the 4 women who went into labour spontaneously also needed an emergency Caesarean section for failure to progress in labour. Twenty two of the 33 women (66%) allowed a trial of VBAC delivered during office hours. The average length of labour in women having a vaginal delivery was 7 hours and 6 minutes.

The overall vaginal delivery rate for the women selected to undergo a trial of VBAC was 87.9%. The overall emergency Caesarean section rate was 12.1 % (4 of 33).

During this time the Caesarean section rate fell from 32.2% in 1993 to 11% in 1995. The overall induction of labour rate rose from 22% in 1993 to 45% in 1995.

There were no cases of uterine rupture or of scar dehiscence or perinatal deaths in this series.

DISCUSSION Over the last 15 years, VBAC has become more

widely accepted. As the number of exclusion criteria decrease, more women are being allowed a trial of labour with success rates varying between 64% and 82% (1). At present, the only absolute contra- indications to VBAC are a previous vertical incision in the upper uterine segment, a previous large myo- mectomy and a previous T shaped uterine incision, as these factors are associated with an increased risk of uterine rupture and its attendant high maternal and fetal morbidity and mortality (2). Although there are reports of uterine rupture associated with the use of oxytocin (3,4), its use has been shown to be safe in women with a previous Caesarean section (5). The use of epidural analgesia also appears to be safe for these patients (6).

In this series 30 out of the 45 women (66.7%) with 1 previous Caesarean section underwent a trial of VBAC. This number would have been larger, had there not been a reluctance by some women to have a trial of VBAC even when the specialist advised that this would be safe. This reluctance appeared to be decreasing towards the latter half of the study period and may reflect the increasing awareness of the local success rates for vaginal delivery.

Our liberal policy of offering VBAC to ail suitable women coupled with a low emergency Caesarean section rate for failed induction has contributed to a reduction in the Caesarean section rate from 32.2% in 1993 to 11% in 1995. This decrease in the Caesarean section rate has occurred at a time when the overall

Caesarean section rate for the rest of Western Australia rose to above 20% (7).

In this series 66% of women who underwent a trial of VBAC delivered during ofice hours. This is important in our setting as the theatre staff are not resident in the hospital out of hours. The timing of delivery had implications not only as far as the safety of the patient was concerned but also with regards to cost savings to the hospital.

Previous studies have shown that possible predictors for success in trials of VBAC include the onset of spontaneous labour, a favourable cervix, a smaller baby, a previous vaginal delivery and a nonrecurring indication for the first Caesarean section (1,s). In Lovell’s study (I), only 43% of women induced for postdates delivered vaginally, and a similar rate was also reported by Flamm (5) and Pickhardt (8). This is in contrast to our study where 89.7% of women who were induced delivered vaginally. Possible reasons include a smaller size baby, less prevalence of occipitoposterior position due to induction at an earlier gestation when compared to induction for postdates, as well as an aggressive oxytocin regimen which was started at the time of the ARM. Although our numbers are small, our overall vaginal delivery rate is higher than previous studies which quote figures in the range of 64% to 82% (1,9) and indeed suggests that it may even be higher when labour is electively induced. Large prospective randomized studies would be required to ascertain if elective induction at 38-40 weeks is associated with a higher vaginal delivery rate in women with a previous Caesarean section.

Many obstetricians are reluctant to induce labour in women who have had a previous Caesarean section because of concerns about uterine rupture or a failed induction necessitating a repeat Caesarean section in a woman who might have delivered vaginally had she laboured spontaneously. Several large prospective studies (5,9) have re&irmed the safety of oxytocin in trials of VBAC. Our study demonstrates even higher success rates for vaginal delivery when labour is induced.

A high induction of labour rate in women with a previous Caesarean section may be considered undesirable and appear to substitute one form of intervention for another. However, all our patients are happy with this approach and given the particular problems caused by the geography of the PiIbara region as well as the lack of avdability of %hour specialist care, we feel that such a policy is justified and certainly has a role to play in other remote adequateIy-staffed hospitals.

References 1. Love11 R. Vaginal Delivery after Caesarean Section: Factors

influencing success rates. Aust NZ J Obstet Gynaecof 1%; 36 4-8.

420 ALW. AXD N.Z. JOURNAL OF OBSTETRICS AND GYNAECOLOGY

2.Lavin JP, Stephens RJ, Miodovnik M, Barden TP. Vaginal Delivery in Patients with a Prior Cesarean Section. Obstet Gynecol 1982: 59: 135-148.

3. Jones RO. Nagashima AW, Hamett-Goodman MM, Goodlin RC. Rupture of Low Transverse Cesarean Scars during Trial of Labour. Obstet Gynecol 1991: 77: 815-817.

4. Scott JR. Mandatory Trial of Labour after Cesarean Delivery: A n Alternative View Point. Obstet Gynecol 1991: 77: 811-814.

5. FIamm BL, Goings JR, Fuelberth NJ, Fischermann E. Jones C , Hersh E. Oxvtocin durine Labour after Previous Cesarean

6.PheIan JP, Clark SL, Diaz F, Paul RH. Vaginal Birth After Cesarean. Am J Obstet Gynecol 1987; 157: 1510-1515.

7. Gee V. Twelfth Annual Report of the Western Australian Midwives' Notification System. December 1995. Health Department of Western Australia.

8. Pickhardt MG, Martin JN, Meydrech EF et al. Vaginal birth after Cesarean Delivery: Are there useful and valid predictors of success or failure?Am J Obstet Gynecol 1992; 166: 1811-1815.

9. FIamm BL, Goings JR, Liu Y. Wotde-Tsadik G. Elective Repeat - Section: Results of a Multicenter Study. Obstet Gynecol 1987: 70: 709-712.

Cesarean Delivery versus Trial of Labour: A Prospective Multicenter Study. Obstet Gynecol 1994: 83: 927-932.

Aust. Nz J Obstet Gynaecol 1996; 3 6 4: 420

IS 'Herbal Health Tonic'Safe in Pregnancy; Fetal Alcohol Syndrome Revisited

V.K. Pradeepkumar,' MRCP, K.W. Tan,' M Med (Paed) and NG Ivy,l M Med (Paed) Department of Neonatology II, Kandang Kerbau Hospital' and Department of Paediatrics and Genetics Unit,'

Singapore General Hospital, Singapore

EDITORZAL COMMENT: We accepted this case report for publication because of the warning it carries that herbal health tonics may have an alcohol content ranging fmm I4 to 40% and could cause the fetal alcohol syndrome even when the mother 'denies exposure to alcohol or any other drugs '. These tonics wherever they are sold, should be labelled appmpriately to indicate the alcohol content and warning of fetal hazard if consumed during pregnancy. Both Asian and nun-Asian members of our population should be informed of the possible dangers of herbal health tonics.

Summary: So called 'Herbal Health Tonics' are freely available in the market. This has been promoted by the manufacturers for the following symptoms: poor appetite, gastrwnteric weakness, poor blood circulation, chills. fatigue, weak constitution and weakness after disease.

We report a case of suspected fetal alcohol syndrome (FAS). A baby boy of 3.700 g born to a 29-year-old Chinese mother at 41 weeks' gestation was found to have features consistent with FAS. On follow up at 3 years of age. both motor and mental milestones as well as speech and language were delayed suggesting the possibility of FAS. There was a history of maternal ingestion of 'Herbal Health Tonic' (which contained 14% alcohol) daily for the first 2 months of the antenatal period. She denied exposure to alcohol or any other drugs.

The authors would like to highlight the risk of such 'Herbal Health Tonics' in pregnancy and their probable deleterious effects on the growing fetus. We feel that i t is extremely important to look into the traditional practices among pregnant women in Singapore and in other parts of the world where there are similar practices, otherwise more cases like these could occur in future.

Address for correspondence: Dr V.K. Pradeepkumar, Dqartment of Neonatology n, Kandang Kerbau Hospital, Singapore, 219428.