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The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest. CLINICAL. RISK. VAGINAL BIRTH AFTER CAESAREAN SECTION. Alternative: Trial of Scar or Trial of Vaginal Delivery Not Trial of Labour. Roger V Clements Editor:Clinical Risk. CLINICAL. RISK. V B A C.
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The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

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CLINICAL RISK VAGINAL BIRTH AFTER Cesarean SECTION Alternative: Trial of Scar or Trial of Vaginal Delivery Not Trial of Labor Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture (Meta Analysis - Dickinson) Enkin (1989) 4153 0.8% Miller (1994) 10880 0.6% Flamm (1994) 5022 0.8% McMahon (1996) 3249 0.3% Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture (Meta Analysis - Clements) Rosen (1991) >6000 c2% Scott (1991) 196 1.5% ACOG (1994) ? 2.0% Roger V Clements Editor:Clinical Risk

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CLINICAL RISK VAGINAL BIRTH AFTER Cesarean SECTION Risks of Cesarean area Maternal Mortality of Elective Cesarean Section is of the request of 1 in 10,000 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture Is there an obligation to caution? Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "I am not mindful of any sound VBAC concentrate that did not report antagonistic results… . Gleicher N (1991) Letter. Obstetrics & Gynecology 78.4.727 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "Nor am I mindful of any VBAC defender who might not instruct patients with respect to the danger of crack amid work… ... Gleicher N (1991) Letter. Obstetrics & Gynecology 78.4.727 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "The question is not whether uterine crack happens; we know it does… . Gleicher N (1991) Letter. Obstetrics & Gynecology 78.4.727 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "The genuine question is, the thing that rate of antagonistic result are we willing to acknowledge?" Gleicher N (1991) Letter. Obstetrics & Gynecology 78.4.727 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "Scott makes a legitimate point in expressing that break rates are underreported… … . Gleicher N (1991) Letter. Obstetrics & Gynecology 78.4.727 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "Notwithstanding, the question ought to be what are accounted for rates of crack as well as what is a worthy rate of break inside a specific organization" Gleicher N (1991) Letter. Obstetrics & Gynecology 78.4.727 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "the primary concern is that neither VBAC nor it(s) option are without hazard… ..the best arrangement is to make it more secure... Flamm B.L. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53 11 661-662 1998 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "A huge investigation of uterine break found that all babies did well if conveyed inside 17 minutes of the onset of a drawn out deceleration. Flamm B.L. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53 11 661-662 1998 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "However the primary danger of VBAC is uterine burst. This happens in 1 percent of patients. Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53. 11 662-663 1998 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "In addition, the hazard is notwithstanding the typical dangers connected with a trial of work in patients without an uterine scar… … . Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53. 11 662-663 1998 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Risk of Rupture "I comprehend that if my uterus breaks amid my VBAC, there may not be adequate time to work and to keep the demise of or perpetual mind harm to my infant" Phelan J.P. Vaginal birth after cesarean: where have we been and where are we going? Obstetrical and Gynecological Survey 53. 11 662-663 1998 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C What the Textbooks Recommend Eligibility 1 past lscs - no other unfavorable components Twins, breech & non diabetic macrosomia More than one past lscs is dubious Patient inclination may impact decision Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C What the Textbooks Recommend Eligibility Generally acknowledged contraindications include: past established cesarean segment diabetic macrosomic hatchling Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C What the Textbooks Recommend Conduct Critical audit of advance of work Continuous fetal heart rate checking The issues of intravenous get to and cross-coordinating of blood are more questionable Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C What the Textbooks Recommend Conduct Prostaglandins might be utilized - no more! Alert ought to be practiced with oxytocin Regional absense of pain not contraindicated Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C What the Literature says Prostaglandins " For ladies with one earlier cesarean conveyance, the danger of uterine crack is higher among those whose work is instigated than among those with rehashed cesarean conveyance without work . Work actuated with prostaglandins presents the most noteworthy hazard" Lydon-Rochelle et al \'Danger of uterine break amid work among ladies with an earlier cesarean conveyance\' N Eng J Med Vol 343:1:3-8 July5th 2001 Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Personal Series 31 taking after LSCS 1 took after myomectomy Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Personal Series 31 after LSCS In just three case did there appear to me to be no rupture of obligation Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Personal Series 31 after LSCS 9 moms were harmed 27 infants were either harmed or kicked the bucket In 5 cases both mother and child were harmed Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Personal Series 9 Maternal Injuries 2 Hysterectomies (one with mind harm taking after delayed stun) 1 Delayed hysterectomy (accreta) 5 Bladder Injuries (counting two vesico-vaginal fistulae) 1 Psychiatric (after deferred acknowledgment) Roger V Clements Editor:Clinical Risk

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CLINICAL RISK V B A C Personal Series 27 Fetal Injuries 4 Stillbirths 9 Neonatal Deaths 14 Survivors with Cerebral Palsy Roger V Clements Editor:Clinical Risk

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The AVMA Medical and Legal Journal Incorporating Healthcare & Law Digest

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