Vaginal Delivery under Caudal Analgesia after Caesarean Section and other Major Uterine Surgery

Abstract

leucocyte ascorbic acid level within the normal range; after operation 66% achieved normal status. This improvement in ascorbic acid nutrition, however, did not correlate well with the improvement in dietary intake, and only when one considered those in whom both dietary and leucocyte ascorbic acid levels were subnormal before operation did this correlation achieve significance (Fig. 2). This paradox may be explained on the grounds that, whereas the leucocyte ascorbic acid estimations were accurate, the dietary ascorbic acid levels were of necessity only approximations, which lessened the likelihood of good statistical correlation.An alternative explanation, however, is that another factor is involved-an alteration in the absorption or utilization of ascorbic acid after vagotomy. It is striking that, in spite of the return to a full normal diet, the improvement in nutritional status is small, and that even those whose leucocyte ascorbic acid levels were converted to normal remain at the lower limit of normality. The absorption of ascorbic acid is known to be impaired by achlorhydria (Alt, Chinn, and Farmer, 1939), and it has been suggested that the therapeutic hypochlorhydria induced by vagotomy might result in malabsorption of ascorbic acid (Cohen and Duncan, 1967). In this study the reduction in peak half-hour output of acid was taken as an index of reduced gastric acidity, and there was a good negative correlation between this and the postoperative levels of leucocyte ascorbic acid. This finding lends weight to the argument that the hypochlorhydria induced by vagotomy was responsible for the failure of the ascorbic acid nutritional status to improve as much as might have been expected.Animal experiments have shown that ascorbic acid is essential for the formation of mature collagen in healing wounds (Robertson and Schwartz, 1953), and there is a high incidence of poor ascorbic acid nutrition in patients suffering from wound dehiscence (Crandon et al., 1958). It is evident, then, that poor ascorbic acid nutrition represents a hazard to patients undergoing surgery.From our findings one might postulate that the accepted minimum intake of 30 mg/day for normal subjects is insufficient for patients suffering from peptic ulcer, even after surgical treatment. It would seem to be a wise precaution routinely to administer ascorbic acid supplements not only to peptic ulcer patients before operation but to any patient undergoing surgery on whom a vagotomy has previously been performed. JOHN STALLWORTHY British Medical3Journal, 1972, 2, 740-742 Summary In the absence of a recurring indication for caesarean section vaginal delivery in subsequent pregnancy is a "trial of scar," with potentially serious implications for mother and baby. Labour under caudal analgesia was carefully supervised for 75 women with a surgically scarred uterus-due to lower segment section in 72, abdominal hysterotomy in one, and transcavity myomectomy in two. Every caesarean scar was assessed digitally during labour and every uterus was examin...

Trial of scar—is it safe in developing countries?

“…We feel that the clinical assessment during the index pregnancy, especially towards term, was most important in deciding whether to go along with the trial. A very high success rate of between 66.7 per cent and 93.3 per cent has been reported with properly selected cases for trial 8 , 11–14 , and our figure of 75.3 per cent is comparable. In addition, our results have been achieved with virtually the absence of sophisticated monitoring devices.…”

“…When induction of labour was required, the procedure was found to be safe 15 and the use of prostaglandin vaginal pessaries was effective 14 . Previous concern about the use of oxytocin infusion in this group of patients 16 was not substantiated, since this drug was found to be associated with an uncomplicated and successful outcome in most cases 11–13 . Our single case of uterine rupture associated with the use of oxytocin might not be attributable to the drug itself, since there was no clinical suspicion of excessive uterine stimulation.…”

“…Adequate pain relief during labour was beneficial and imposed no additional risk, as lower abdominal pain and uterine tenderness were unreliable signs of uterine rupture 17 . With sufficient pain relief such as that provided by caudal analgesia 12 , instrumental delivery and vaginal examination of the uterine scar were facilitated. If the uterine rupture caused bleeding, changes in maternal heart rate and blood pressure would be the earliest signs 12 .…”

“…With sufficient pain relief such as that provided by caudal analgesia 12 , instrumental delivery and vaginal examination of the uterine scar were facilitated. If the uterine rupture caused bleeding, changes in maternal heart rate and blood pressure would be the earliest signs 12 . Suspected asymptomatic rupture of the scar, or defects or dehiscence discovered on examination, could be managed conservatively 6 .…”