Few studies have focused specifically on the intrapartum management of patients following a prior caesarean delivery. Contemporary assessments and recommendations on attempting vaginal birth after caesarean delivery (VBAC) vary. The actual conduct of labour and delivery of the infant in an uncomplicated trial of labour after caesarean (TOLAC) is similar to the management of a patient without a previous caesarean. Intrapartum management of TOLAC differs primarily in the need for caution with induction of labour in women with an unfavourable cervix, the avoidance of overstimulation with oxytocin augmentation, and surveillance for prompt recognition of the rare case of uterine rupture.

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BRITISH MEDICAL JOURNAL 1 APRIL 1978 825 cortisol concentration was 3174 nmol/l (115 fg/100 ml) at 9 am and 2981 nmoljl (108 KLg/100 ml) at midnight, while there was no suppression after giving 8 mg dexamethasone. Bronchoscopy showed a tumour of the left upper lobe bronchus. His condition rapidly deteriorated, and he died six weeks after admission. Necropsy showed an oat cell carcinoma of the left upper lobe bronchus with widespread metastasis. Both adrenals were twice normal size because of diffuse cortical hyperplasia. The pituitary was normal. There was no evidence of lymphoma, leukaemia, or myeloma. DiscussionIn idiopathic late-onset immunoglobin deficiency there is usually an interval of several years before the malignancy develops,2 whereas in this patient both conditions presented together. Agammaglobulinaemia may complicate lymphoma, chronic lymphatic leukaemia, and myeloma but is not a feature of other malignancies. The exact relationship, if any, between the malignancy and the immune deficiency in this patient therefore remains obscure.Since side effects from corticosteroids are so common it was assumed at first that they were partly responsible for both his oedema and hypokalaemia. In retrospect clearly this was not so: the severity of the metabolic upset was out of keeping with the 7-mg dose of prednisolone he was receiving. The biochemical and histological changes were typical of ectopic ACTH-production, as was his rapid deterioration.3 It is important to remember that, although drugs may cause many diseases, in each case alternative aetiologies should also be considered.I thank Dr P W R Harris for permission to report this case; Dr P Forgacs, who kindly performed the respiratory function tests; Mr A R Makey for the bronchoscopy; and Dr Max Millard for the necropsy. Management of cervical pregnancy with-circumsuture and intracervical obturator A gynaecologist may encounter a cervical pregnancy only once or twice in his professional lifetime, but there is no knowing at what stage of his training the first time will be. The inexperienced may be taken aback at the very considerable haemorrhage that can occur in such a case and the technique we describe in the following history is of value, not only as a first-aid measure, but also as a definitive treatment which aims at avoiding hysterectomy. Case reportA 22-year-old unmarried foreign girl was referred to a private nursing home for termination of pregnancy on psychiatric grounds, having had 12 weeks' amenorrhoea at the time. Her only previous pregnancy had been terminated at eight weeks, two years before. At operation a soft pelvic mass the size of a 12-week pregnancy was found pushing the uterine body, a small firm mass, upwards and forwards. A thin effaced external cervical os was found to admit a finger and the pregnancy was terminated by aspiration. A large haemorrhage of about 2 1 occurred, and digital examination, which disclosed a cavernous cervical canal with a closed internal os, enabled a diagnosis of cervical pregnancy to be made beyond ...