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Ninety years ago, virtually all cesareans were done through a classical incision. The risks to mother and fetus from the rupture of a classical cesarean incision exceed by far what is acceptable in obstetrics today. The classical scar in the upper muscular body of the uterus can tear directly into the peritoneal cavity. About 40 percent of the time the placenta is implanted on the front wall of the uterus under the scar and the rupture therefore initiates placental separation and consequent hemorrhage. Contractions of the uterus tend to push placenta and baby out through the defect whether or not the woman is in labor. If the placenta is on the back wall of the uterus, the baby is pushed into the peritoneal cavity and the placenta follows. The separation of the placenta cuts the baby off from its maternal support system and the fetus is likely to die of asphyxia, before it can be rescued by an abdominal operation. The inevitable serious hemorrhage in the mother due to this calamity results in a hundred­fold increase in the maternal death rate. A planned, or elective, repeat cesarean will be scheduled at about 36 to 37 weeks of pregnancy in the few women who today have had classical cesarean deliveries.

When a previous low transverse scar ruptures, the body of the uterus usually remains intact. Uterine contractions, instead of causing the fetus to erupt into the peritoneal cavity, simply continue to push the baby down further into the birth canal. Since the placenta and its blood supply are in the body of the uterus, placental separation does not take place and bleeding usually is negligible. The baby remains in a position from which it can be delivered readily. The risks to mother and baby are only slightly greater than those of a normal pregnancy. The previous incision is not likely to be disrupted by a later twin pregnancy, by the presence of hydramnias, or by the stretching of the uterus to accommodate a baby much larger than the previous one.

Many studies do not make a distinction between serious and minor rupture of the uterus. Thus, the rate of dangerous rupture cannot be evaluated completely, but most studies report that less than 1 percent of VBACs result in uterine rupture. In most cases, this is not dangerous to mother or baby.

Today, women who have had previous cesarean deliveries are given the option of a vaginal birth for their next pregnancy. Often, this is referred to as a “trial of labor,” meaning that a cesarean will be performed if the labor is not successful. Studies have shown that women who have vaginal births have lower rates of fever, infection, and bleeding, although there is the small increased risk of uterine rupture with a trial of labor. For this reason, the American College of Obstetricians and Gynecologists advises that women with previous cesarean deliveries have their subsequent deliveries in a hospital with the capacity to perform an emergency cesarean operation if necessary.

Generally, in order to have a trial of labor, there will have to be documentation of the type of incision used in the cesarean. If you are delivering at the same hospital or with the same obstetrical practice, this is no problem. If you are not, you should request that your medical records be sent to your new physician or midwife early in your pregnancy. If, for whatever reason, you cannot get this documentation, then a careful history will be taken. If your cesarean was done for a baby that was premature, then it will be assumed to have been a classical incision, and you will not be able to labor. In most other cases, the scar will be assumed to be in the lower uterine segment and you will be able to labor, with close observation.

In most of the studies in which women with previous cesarean deliveries have gone into labor, 60 to 70 percent delivered vaginally and uneventfully. Some researchers have attempted to predict which women will experience successful vaginal delivery after cesarean and which will need a repeat cesarean. To date, this prediction has not been possible. The only consistent variable that seems to make VBAC more successful is having had a previous vaginal birth in addition to the previous cesarean. Some researchers have tried measuring the thickness of the lower uterine segment with ultrasound prior to the trial of labor. This may be promising for the future, but currently there is not enough data on this technique to use it to select women for a trial of labor.

Some practitioners examine(with gloved fingers) the scar inside the uterus immediately after the birth of the baby in a woman who has had a vaginal birth following a cesarean to be certain that it has remained intact. Unless active bleeding is present, however, a separation of the old scar, called a dehiscence, does not need to be repaired. This examination. then, may be unnecessary unless unusual bleeding is present.

Women who have delivered previously only by cesarean and who then deliver via the vagina are naturally pleased to find that the recovery from a vaginal birth is more comfortable and speedier than recovery from an abdominal delivery.

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Studies have found that these medications, given intravenously, stop labor for a day or two, at most. While this doesn’t give the fetus much time to grow, it may allow for the adminstration of corticosteroids or maternal transfer.

Since beta-adrenergic receptors are found in smooth muscle cells all over the body, these drugs affect many body systems. This limits their use. They can cause heart and lung problems, as serious as rapid or irregular heartbeat, decreased blood pressure, chest pain, and pulmonary edema(fluid in the lungs). They cause changes in body chemistry, including increased blood sugar, decreased blood potassium, and increased blood insulin levels. They cause less serious but quite unpleasant side effects such as vomiting, headaches, fever, and hallucinations. They may cause anxiety in the woman.

Women receiving ritodrine or terbutaline must be hospitalized and watched with extreme care. Women with poorly controlled diabetes or poorly controlled high blood pressure should not be given beta-adrenergic agonists.

Magnesium Sulfate. Another medication used in the effort to stop preterm labor is magnesium sulfate, usually given intravenously. Studies show its effects on labor to vary from none to stopping labor for the same duration as ritodrine. Magnesium can depress maternal respiration, although this effect is rare. A woman must be closely observed while the drug is being given. Magnesium therapy may also cause nausea and vomiting, decreased blood pressure, and headache. Magnesium eventually crosses the placenta and may affect newborn respirations as well.

Magnesium sulfate cannot be used in women with kidney failure, low blood calcium levels, or a disease called myasthenia gravis(characterized by severe muscle weakness).

Prostaglandin Inhibitors. Prostaglandins are a group of body chemicals involved in normal uterine contractions. Prostaglandins can be given to induce labor. Conversely, prostaglandin inhibitors can be used to stop labor. These inhibitors work by either reducing the formation of prostaglandins or blocking their action. Indomethacin is an example of a prostaglandin inhibitor that has been used to arrest labor.

Research studies have found prostaglandin inhibitors more effective than beta-agonists for delaying labor up to 48 hours, with fewer maternal side effects. Prostaglandin inhibitors, however, are associated with severe adverse effects on the fetus, including cardiac defects and brain hemorrhage. They can also cause bleeding in the mother. The use of these drugs for stopping labor is still under investigation.

Indomethacin cannot be used with maternal asthma, coronary artery disease, gastrointestinal bleeding, kidney failure, and oligohydramnios. Suspected heart or kidney abnormalities in the fetus also preclude its use.

Calcium Channel Blocking Agents. Reducing calcium levels in muscle cells reduces muscle contraction. Calcium channel blockers stop the entry of calcium into cells. (These drugs are used to treat high blood pressure because they relax the muscles in blood vessels.) An example of a calcium channel blocker that has been used to stop preterm labor is nifedipine.

Studies have shown that nifedipine can postpone delivery by 3 days­a greater delay than that seen with ritodrine. Maternal side effects are less than with ritodrine. The effect of this drug on the fetus, however, has not been studied extensively. Because it relaxes the muscles in blood vessels, it could lead to decreased blood pressure in the mother. This, in turn, could lead to decreased blood flow to the placenta. The extent to which this occurs warrants further study.

Nifedipine should not be used with magnesium sulfate as it enhances the effect of magnesium, leading to serious lung and heart problems. Women with liver disease cannot use nifedipine.

Oxytocin Inhibitors. Atosiban is a type of drug currently under development. It works by inhibiting oxytocin, a chemical responsible for uterine contractions. Its use has been limited but it may prove to be beneficial in the future.

The search for safer and more predictable drugs continues. It is difficult to slow down or speed up the uterus without affecting other body systems. The best drug would be one that limits its effects to the uterine muscle. Such a substance has not been identified.

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All forceps have two curves-one to fit the curve of the birth canal and the other to allow the blades to wrap properly around the baby’s head. These curves vary slightly from one forceps to another. The Simpson forceps, the Tucker-McLane forceps, the Luikart forceps, an instrument more slender and delicate than the first two, and the Kielland forceps, the most delicate of all, are most commonly used in the United States. The experience of an individual operator with a particular pair of forceps is probably more important to successful use than the particular variety of instrument used for a given delivery.

When Are Forceps Used?

The reasons for forceps delivery are divided into two broad classes, the fetal and the maternal.

коли под наемFetal Reasons for Forceps

The fetal indication for forceps is evidence of fetal distress appearing in the second stage of labor. This might be a persistent nonreassuring fetal heart rate pattern, with the awareness that some decelerations are perfectly normal in the second stage of labor. It might be a prolapsed umbilical cord or a separation of the placenta.

Maternal Reasons for Forceps

Maternal indications for forceps are not very clear-cut. A woman with a disease of the heart or lungs may have difficulty pushing. Sometimes a woman is able to bring the baby’s head into view at the entrance to the vagina but somehow lacks the strength for the final pushes. Women who are unfortunate enough to have had a long latent labor, especially if they have gone without solid food and sleep, may reach the second stage of labor fatigued and distraught, and may have difficulty pushing well. If contractions are strong and the baby is in a good position, usually they can manage. However, if the baby is posterior, for example, second stage may be prolonged, and maternal exhaustion may become great. If the head is low enough, forceps may be worthwhile in such a situation.

Safe Conditions for a Forceps Delivery

Delivery by forceps is safe only if specific conditions are met. The fetus must be in a vertex or face presentation. In a face presentation, the chin must be anterior(facing the mother’s front). The head of the child must fit deeply into the pelvis without serious obstruction from the mother’s pelvic bones. To ascertain this, the head must be engaged­wedged between the ischial spines of the mother’s pelvis. This also is called 0(zero) station. The membranes must be ruptured, and the cervix completely dilated. The physician applying forceps must be certain of the position of the fetal head so the forceps can be applied properly. When the baby is presenting as a breech, forceps can be used, but only for the aftercoming head-after the breech and body have been born.

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In the first stage of labor, the amniotic sac breaks, causing a rush of fluid from the vagina(commonly referred to as “breaking of the waters”). Contractions in the abdomen and lower back also signal the beginning of labor. Early contractions push the baby downward, putting pressure on the cervix and thereby causing it to dilate further. The first stage of labor may last from a couple of hours to more than a day for a first birth, but is usually much shorter during subsequent births.

The end of the first stage of labor, called transition, is the process when the cervix becomes fully dilated and the baby’s head begins to move into the vagina, or the birth canal. Contractions usually come quickly during transition. Transition usually lasts 30 minutes or less.

The second stage of labor follows transition when the cervix has become fully dilated. Contractions become rhythmic, stronger, and more painful as the uterus works to push the baby through the birth canal. The second stage of labor(called the expulsion stage) may last between one and four hours and concludes when the infant is finally pushed out of the mother’s body. In some cases, the attending practitioner will do an episiotomy, a straight incision in the mother’s perineum, to prevent the baby’s head from causing tearing of vaginal tissues and to speed the baby’s exit from the vagina. Sometimes women can avoid the need for an episiotomy by exercising and getting good nutrition throughout pregnancy, by trying different birth positions, or by having an attendant massage the perineal tissue. However, the skin’s natural elasticity and the baby’s size are limiting factors.

After delivery, the attending practitioner cleans the baby’s mucus-filled breathing passages, and the baby takes its first breath, generally accompanied by a loud wail.

In the meantime, the mother continues into the third stage of labor, during which the placenta, or afterbirth, is expelled from the womb. This stage is usually completed within 30 minutes after delivery. The umbilical cord is then tied and severed. The stump of cord attached to the baby’s navel dries up and drops off within a few days.

Most mothers prefer to have their new infants placed next to them following the birth. Together with their spouse or partner, they feel a need to share this time of bonding with their infant.

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Without a known cause of preterm labor, treatment is aimed at stopping the contractions, rather than alleviating the cause. This is sometimes effective, although studies have shown that most treatments postpone birth for only 48 hours. This is enough time, however, to give the mother a medication that many experts believe speeds up maturation of the fetal lungs, helping to increase survival. It is also sufficient time to transfer the pregnant woman to a hospital that has a neonatal intensive care unit(NICU), called a tertiary care center or a Level III hospital. This is preferable to transferring a premature infant after birth, which poses more risks for the newborn and separates the mother and baby.

Promoting Fetal Lung Maturity: A corticosteroid drug called betamethasone or dexamethasone is given to the mother to promote fetal lung maturity. This drug is thought to cause the fetal lung to produce surfactant-a chemical that keeps the lungs expanded after each breath. In respiratory distress syndrome(previously called hyaline membrane disease), the lungs of the premature newborn collapse after each breath, making each breath as difficult as the first. This is a major cause of death in premature infants. Surfactant appears in the fetal lung in the second trimester, but may not be present in sufficient quantity to be effective before 34 weeks of pregnancy.

In 1995, the National Institutes of Health(NIH) hailed the use of corticosteroids as a major breakthrough in care for preterm newborns. Since this report, the therapy has been used widely in preterm labor. Recent studies, however, have not consistently supported its value.

For corticosteroids to be beneficial in causing lung maturity, there must be a delay of at least 24 hours between treatment and birth. If birth is delayed for 7 days, their effectiveness is unclear.

Standard regimens for administering the medication vary. One major obstetrical text reports the use of two doses of 12 mg betamethasone, injected into the muscle, 24 hours apart, or 12 hours apart if labor seems likely to occur before 48 hours have passed. Another major text reports use of 5 mg of dexamethasone every 12 hours for four doses. The therapy may be repeated every 7 days until 34 weeks gestation, although some controversy exists about whether repeated courses of steroid treatment might impair brain or immune system development in the fetus. More research is needed in this area.

Stopping Labor: Various drugs have been used to stop preterm labor, including beta-adrenergic receptor agonists, magnesium sulfate, prostaglandin inhibitors, calcium channel blocking agents, and oxytocin inhibitors. The act of stopping uterine contractions is called tocolysis(Greek: tocos = birth; lysis = dissolution). Women with medical diseases may not be able to use some or any of these drugs as they aggravate certain conditions.

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