How Predictive is CTG of Scar Rupture in VBAC?

Varsha Jain and Ann Daly Birmingham Womens Hospital

Aims and Objectives

Review current evidence re: CTG and scar rupture in VBAC Critically appraise a study

The clinical question

Does continuous monitoring with CTG help us to identify scar rupture in vaginal birth after section? Question identified from a morning CTG meeting

Literature Search
Sources:
Cochrane Pubmed MIDIRS

Search terms:
Cardiotocography (MeSH) Uterine rupture (MeSH)

Guidelines
BWH guidelines state:
 

Very low risk of scar rupture in planned VBAC (0.5%) Features to identify scar rupture:
       

Abnormal CTG Severe abdominal pain, esp in between contractions Chest pain/SOB/shoulder tip pain Acute onset scar tenderness Cessation of previously efficient uterine activity Maternal tachycardia, hypotension. Shock Loss of station of presenting part Vaginal bleeding

Category 1 section & incident form

Risk of augmentation
Decision to induce should be a consultant led decision Risk of scar rupture in
Induced 102 in 100,000 (1.02%) Augmented 87 in 100,000 (0.87%) Spontaneous 36 in 100,000 (0.36%)

Literature Search Results

Three papers identified 1. Diagnostic potential of CTG for silent uterine rupture Acta Obstet Gynecol Scand 1989 68 (7) 653-6 (3 patients, CTG done, but uterine rupture not identified until section) 2. A ten year review of uterine rupture in modern obstetric practice Ann Acad Med Singapore 1995 24 (6) 830-5 Symptoms and Signs with scar rupture value of uterine activity measurements Aust N Z J Obstet Gynaecol 1992 32 (3) 208-12

3.

Papers selected
2.

A ten year review of uterine rupture in modern obstetric practice Ann Acad Med Singapore 1995 24 (6)
830-5

3.

Symptoms and Signs with scar rupture value of uterine activity measurements Aust N Z J Obstet Gynaecol
1992 32 (3) 208-12

A ten year review of uterine rupture in modern obstetric practice

Study details
Retrospective analysis using theatre records at Kerbau Hospital, Singapore 1983 1992 26 cases of uterine rupture or scar dehiscence Of the 26, 20 cases had previous LSCS Most common presentation (25%) was abnormal CTG (variable or late decelerations or early decelerations with other signs of fetal compromise eg m/s liquor)

Symptoms and Signs with scar rupture value of uterine activity measurements Study details National University Hospital Singapore 1985-1990 24,182 total deliveries CS rate 12.5% (3026) Previous LSCS 4.2% (1018) Of this 70.9% (722) had only one previous CS and trial of labour

Study Details cont.

Of the women who had a trial of labour 70% (506) delivered vaginally 4 cases of incomplete scar rupture
Incomplete scar rupture where uterine myometrium was breached but peritoneum remained intact

5 cases of complete scar rupture

Complete scar rupture where both uterine myometrium and peritoneum were breached

CTG appearances of fetal distress or sudden decrease in uterine activity

Study Findings
No maternal death or severe morbidity (one bladder tear) One fresh stillbirth (hydrocephalus) One neonatal death All 9 cases had oxytocin infusion

Critical appraisal (CASP)

Was the study type appropriate to answer the question? Both studies were retrospective analysis of labour records yes this is an appropriate study to answer this type of question

Critical appraisal
Were confounding factors accounted for? Parity Number of previous C/S Previous vaginal deliveries Size of baby Use of oxytocin Duration of labour Age of mother? Ethnicity? Any more .

Will the results help us manage our patients?

Useful to look at study results to see how patients can present Useful to see types of CTG changes Not so useful as continuous CTG will still be needed Practice in this hospital will not change based on these studies a pre-existing BWH thorough guideline

Conclusion
Review of current guidelines in relation to VBAC and scar rupture Presented two studies total of 29 cases CTG monitoring is needed as can show helpful signs Need to consider full clinical picture Need more recent research and larger study numbers