Vaginal birth after cesarean section - a continuing challenge

The purpose of this study was to assess the antenatal and intrapartum factors influencing the success of vaginal delivery in women with one cesarean section. Identification of modifiable risk factors which could help in developing local guidelines to improve the management and success rate of patients undergoing vaginal delivery after one previous cesarean section. Prospective cohort study. This study was carried out at the Department of Obstetrics and Gynecology, Aga Khan University, Hospital, Karachi from 01.01.2008 to 30.06.2008. A sample size of 21 women, undergoing induction of labor [IOL] and 54 women with spontaneous labor were needed. All women with singleton, cephalic, term pregnancies with history of previous one caesarean section were included. Data collected through the Performa and statistical analysis performed using the SPSS computer statistics programme. To compare proportions, the x[2] test and Fisher's exact test were used and student-t test were used to compare means. Both groups were comparable and there was no statistical difference between them, except for the Bishop score which in the induction of labor [IOL] group was 4 +/- 1.54 and in the spontaneous labor group was 5.7 +/- 2.18, which is statistically significant [p value = 0.001]. The results suggest that there is no effect of previous vaginal delivery, epidural analgesia, fetal distress and baby's gender on the outcome of trial of labor [TOL]. The rate of successful vaginal birth after cesarean section [VBAC] is not significantly different in the group of IOL and spontaneous labor. The current clinical evidence suggests that VBAC is advantageous to the mother and has no adverse effects on the fetus but it is no risk free. It is actually the responsibility of the obstetrician to ensure best care and appropriate management plan

Knowledge of medical students about obstetric fistula in Pakistan still a tragedy

To assess the knowledge of medical students about obstetric fistula in Pakistan-still a tragedy. Cross sectional study. This study was conducted at Hamdard University Hospital, Karachi from 01.01.2014 to 15.03.2014. A cross sectional study of knowledge of medical students of Final Year MBBS was conducted using a pretested self-administered questionnaire. Total 100 questionnaires were filled out of which, 87 were filled by medical students and 13 by house officers. The data was evaluated and analysed on SPSS. The results shows that the overall knowledge of our students and junior doctors regarding obstetric fistula was below average. They are not well aware of the substantial burden of obstetric fistula in our community, its root causes and preventive measures to be taken. This shows the need to giving more weightage to this topic in curriculum and re-structuring their training program. The presence of trained professional is crucial for the early detection and timely management of such complications. To achieve this within limited resources these students and young doctors are an important cadre of health professionals, therefore the curriculum should lay emphasis on community based clinically oriented teaching

Evaluation of tubal patency by hysterosalpingograhy in infertile patients

To evaluate tubal patency by hysterosalpingography in infertile patients. This prospective study was carried out on 200 female subjects, with primary and secondary infertility aged 20-41 years, attending the Department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore, from 1997 to 1999. After detailed history, thorough clinical examination and investigations, all the patients underwent hysterosalpingography during the proliferative phase of cycle and the findings recorded. The age of 100 patients included in the study varied from 20-40 year in primary infertility and 20-45 in secondary infertility. An evaluation of the status of the tubes assessed by each of the two techniques. HSG showed bilateral peritubal adhesion in one patient and unilateral peritubal adhesions in 2 patients. It is evident that HSG is more informative in uterine malformation while laparoscopy gave extra information like polycystic ovaries, subserous fibroid and endometriosis, which are totally missed by HSG. Hysterosalpingography is a valuable tool in assessing tubal patency. In addition it gives information regarding contour of urine cavity, any uterine malformations, level of obstruction in fallopian tubes and presence of any hydrosalpinx

Laparoscopic findings in patients with infertility

To evaluate laparosocpic findings in patients with infertility both primary and secondary. This prospective study was carried out on two hundred female subjects with primary and secondary infertility aged 20-45 years, attending the department of Obstetrics and Gynaecology, Jinnah Hospital, Lahore during the period of 1997 to 1999. A detailed history taken and physical examination was done. All relevant investigations were done and then laparoscopy was performed and findings recorded. Both tubes were found to be patent in 83.5% of patients with primary infertility and 69% of patients with secondary infertility. Bilateral tubal blockage was present in 9% of patients with primary infertility and 20% of patients with secondary infertility. Bilateral pelvic adhesions were present in 10% of patients with primary infertility and 28% of patients with secondary infertility. Bilateral hydrosalpinx was found in 6.75% of patients with primary infertility and 12.5% of patients with secondary infertility. Laparasopy is useful in assessing tubal patency. In addition it provides information about presence of peritubal and ovarian adhesions, presence of polycystic ovaries and endometriosis as it allows direct visualization of pelvic cavity

Multiple pregnancies-maternal and fetal outcome

This study was carried-out on all patients with multiple gestation, who delivered in Unit - I, Lady Willingdon Hospital, from October 2000 to March 2003. A total of 10391 women delivered during this 21/2 years period, out of these 179 had multiple births -176 had twin delivery and three gave births to triplets. The aim of the study was to find out frequency of multiple births and maternal and neonatal outcome in these cases. The prevalence of multiple births was 1.72% with 1.69% of twins and 0.029% triplets. Women with multiple pregnancy were found to be at high risk of pre-term delivery and about 34% of babies were between 1-2 Kg. The rate of caesarean section was also significantly high in these women

Frequency, presentation and management of fibroid uterus

The study was carried-out in Unit - I, Department of Obstetrics and Gynaecology Lady Willingdon Hospital, Lahore from January 2001 to December 2002. A total of 164 women with fibroid uterus were managed during this period. The objective of this study is to find out frequency and presentation of fibroids and to evaluate surgical treatment of women with fibroid uterus. Out of 164 cases, 47 had diagnostic D and C and were managed medically. Out of the rest 117 patients, 23 patients underwent myomectomy after diagnostic D and C. Ninety-three patients had abdominal hysterectomy while only one had vaginal hysterectomy. During operation, haemorrhage was the only complication which occurred in nine cases of myomectomy and intra-operative blood transfusion was done. Patients were followed- up for a period of six weeks to six months. There was no delayed complication or mortality in our study

Uterovaginal prolapse

This cross-sectional study included 160 patients with uterovaginal prolapse managed in Unit - I, Lady Willingdon Hospital, Lahore from January 2001 to December, 2002. Vaginal hysterectomy was done in 103 patients, Manchester repair operation in 18, anterior and posterior repair in 10 patients, posterior repair in 6 patients, ring pessary insertion in 3 patients and sling operation in 2 patients. One nulliparous girl who had Manchester repair and 1 elderly woman who had sling operation for post-hystrectomy vault prolapse had recurrence. These patients became asymptomatic after second operation. There was no mortality

Instrumental vaginal deliveries

The objective of this study was to describe trends in instrumental delivery and to find out frequency of maternal and neonatal complications in a large maternity hospital. All 123 patients undergoing instrumental vaginal delivery in Unit-1 were included. The operative vaginal delivery was 1.17% of total births and 1.648% of vaginal deliveries. Of these 68 women had vaccum extractions while, 55 had forceps delivery. Seventy-one patients were primigravida and the commonest indication for instrumental delivery was fetal distress followed by prolonged second stage. Apgar score at 5 min. was more than 5 in 79.6% of babies. There was one still birth in the vaccum extraction group and five neonatal deaths [all due to birth asphyxia]. There were few maternal complications including only one third degree perineal tear