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You are an F1 working in the antenatal clinic. Your next patient is a 35 year old mother who had a previous caesarean section in her last pregnancy.

Patient medications: Pregnacare ®

Please take a full obstetric history and address the patient’s concerns. Perform the appropriate examination. Following this, the examiner will discuss features of the case with you.

You are a 35 year old teacher, called Sue Yu. You presented to clinic today to discuss whether or not you can have a normal vaginal delivery after giving birth by emergency caesarean section during your previous pregnancies.

Current pregnancy You are 28 weeks pregnant and planned this pregnancy with your husband, who is a lawyer. You had no difficulties conceiving and had only stopped using the combined oral contraceptive three months ago. You have a bad memory for dates and are therefore unsure about your estimated delivery date, but you are 28 weeks pregnant according to the scans. You are not sure about your last menstrual period. Your immunisations are up to date and have been taking folic acid since coming off “the pill”.

Antenatal care You are under consultant care “because of your weight”. At your last appointment, you were told that your BMI is 35, which you were horrified about – you know it is far too much. You had an anomaly scan which “was all fine”. Apart from morning sickness, this pregnancy has been absolutely fine. You believe you can feel the baby moving around. You wish your previous pregnancies had been this smooth!

Past obstetric history This is your third pregnancy. You unfortunately lost your first child during labour after “he got stuck” fifteen years ago. You were rushed to theatre for an emergency caesarean and you do not remember much about that pregnancy. It was a difficult time and you would prefer not to discuss the details surrounding that today.

Eight years ago, during your second pregnancy, you gave birth to a girl called Blessing. She is currently in preschool and excels amongst her peers. Blessing weighed 4.3 kg when she was born via emergency caesarean after “Blessing’s heart rate starting to slow down.” You took a long time to recover from the second caesarean section and the wound got infected a few days later. You would prefer to “just have a normal delivery for once!” You did not experience any post-partum mood disorders.

Past gynaecological history Your cervical smears are up to date. Your periods are regular and have never seen a gynaecologist.

PMH You have no known medical problems. You do not see your GP regularly for any reason and have not had any operations apart from the two emergency caesareans.

SH You do not smoke or drink during the pregnancy. You drank a bottle of wine on the weekends and smoked 10 cigarettes a day before trying to conceive. You have never used any recreational drugs.

FH There is no family history of note.

DH You use Pregnacare® which contains folic acid and many other multivitamins. You do not use any over the counter medications. You do not drink coffee, tea, or consume any unpasteurised products. You have no known drug allergies.

ICE You came to clinic to discuss whether or not you can have a normal vaginal delivery after having two emergency caesareans. You’ve done quite a bit of reading on the topic and found an excellent decision aid on a website. You believe you do not need to have Caesarean and would like to try to have a normal vaginal delivery. However, if things are not progressing as planned, and it is in the best interest of your child, you would not mind having another emergency Caesarean.  

The student should elicit Sue’s expectations for her pregnancy and use the obstetric history to determine whether or not she is suitable for a vaginal delivery after a previous caesarean. An obstetric examination would be appropriate. While it unlikely that the foundation doctor would be required to make this decision, it is crucial that they be able to take an adequate history, summarise the salient points and present these to their senior obstetrician.

Discussion points - What can you tell me about normal labour? - What factors lead to failure of labour progression? - How would you manage someone who fails to progress in labour? - Are you aware of any complications of caesarean section? - Why is shared decision making important? - Are decision aids useful in shared decision making?