Question

Classro S 22Section 1. Part 1 PRENATAL CASE STUDIES Client Profile Esparanzanarold P1001 MHF at 36 wa She had a previous an section with an epidural in Mexico six years ago for a breech presentation at werksgestational The hat wriched pound she is five cet two inches and her PPW was 100 pounds She would like a vaginal birth after cesarean sec on (VBAC) with this pregnane, however she saw six doctors before she found one who would even consider doing a VRAG. Case Study paranza seems anxious at today's prenatal visit. She tells the nurse that the baby feels like his head is up under her ribs and she fears another cesarean schon for breech. The following data is obtained at this visit Wt 125 lb FHT 140s URQ Fundal height (FH) 85 cm Fetal movement (FM) Urine chemstrip testing all negative No HA, vision changes No CVAT No edema Questions 1. Why was it so difficult for Esparanza to find an obstetrician who would consider doing a VBAC? Discuss the ethical dilemmas that exist when the de- sires and needs of the client come in conflict with those of the practitioner 2. What are the routine labs for this visit, and why are they done at this time? 3. Compare and contrast VBAC and repeat ce- sarean section for the following: safety for both mother and baby, cost, pain, long-term effects, ef- fects on breastfeeding, and parenting. 4. Her obstetrician asks for her previous cesarean section records before he will even consider a VBAC. Why? 5. Why are cesarean sections usually done for breech presentation? 6. When would a vaginal delivery be considered for a breech presentation? 7. How can the baby be encouraged to move to a cephalic presentation? Figure 1.2 Examples of breech presentations.

Answer 1

Esparanza a 23 year old female is with the gestational age of 36 weeks with a weight of 125lbs.

Foetus : 36 wks i.e. 9 months.

Fungal Height 35 cms

Heart Rate is 140 bpm which is normal for 36 weeks of gestation.

Normal FHR at 36 weeks is 130 to 140 bpm.

To determine why Esparanza found it so difficult to find an obstetrician who would do VBAC , there is a need to know the complications , risk factors etc.

vaginal Birth After Caesarean Section.

VBAC is that to have baby delivered vaginally after having caesarean section in previous delivery.

Is VBAC Safe:

Some sources says that VBAC is safer than repeated caesarean section and the other states that it is more safer in multiple Cesarean section and some says that it is most dangerous.

But it highly depends on some of the risk factors which may be not safe for both mother and the baby.

Factors to be taken in to consideration for VBAC:

1. The condition of previous caesarean scar

2. Hypertension of the mother which are the main cause of pre-eclampsia and eclampsia.

3. Malpositions and Malpresentations

4. Fetal Macrosomia ( large size of the baby)

5. Recent caesarean section

6. Obesity

7. Maternal age greater than 35 yearsetc.

Now let us assess Esparanzas condition applying the above factors.

• Esparanza has no hypertension but when we go through the Case Study it shows that her fetal head is which is touching the ribs. This clearly shows that baby is with Malpresentation I.e. Breech presentation.
• She felt the baby head near the ribs as the baby is in 36 weeks. At 36 weeks the fundal height will be near to symphysis pubis.
• Breech presentation is of different types
• Complete breech presentation,  Footling presentation, Frank Breech and Knee presentation.
• We are unaware of which type of breeze presentation does Esparanza is with and which is very dangerous and also descent does not take place in to the pelvis.
• Her initial caesarean section was done for the same breech presentation.

Above factors are not favourable for caesarean section which is risky both for Esparanza and her baby and so no obstetricians were ready for VBAC.

Ethical Dilemmas :

• Defined result cannot be found, confusion based mostly a trial method.
• Cost and safety related concerns
• Efficacy cannot be expected
• Risk based
• Uterine ruptures : small ruptures in uterus leads to hypoxic ischemic encephalopathy.

Hope this solution helps you.