Vaginal delivery after myomectomy: challenges and opportunities

Abstract

A 33-year-old patient was booked for antenatal care at 6 weeks during her Wrst pregnancy. She had a previous abdominal myomectomy 6 years earlier for heavy periods that made her anaemic. She had a hospital report indicating that the Wbroid was located in the lower posterior uterine wall, encroaching on the cervix and measured 8 £ 7 £ 6 cm. It distorted the uterine cavity and obliterated the pouch of Douglas. The incision was made over the Wbroid, through the posterior wall of the uterus. An opening of half a centimeter was made into the uterine cavity during the operation and the patient was advised to have an elective section. The uterine wall was closed with vicryl, and the peritoneum was closed with prolene. She was counseled about the risk of uterine scar rupture and was oVered an elective caesarean section, which she declined and requested a trial of vaginal delivery. Her pregnancy progressed uneventfully and repeat ultrasound scans showed no signiWcant change in the size of her Wbroids or any thinning of her uterine wall. She was admitted in spontaneous labour 9 days after her due date. A venXon was inserted, blood taken for group and save, and an epidural sited. She was kept under continuous cardiotocography monitoring. She progressed from 5 cm cervical dilatation to 9 cm in 4 h. The patient then took 4 h to reach full dilatation, as the vertex rotated from occiptoposterior position to right occiptoanterior position. There was no progress, despite an hour of pushing and the patient was counseled again regarding the need for emergency section, but insisted on continuing the trial. There was no progress despite an hour of pushing and the patient was counseled regarding the need for emergency section, but insisted on continuing the trial. The consultant was called in and agreed to a trial of instrumental delivery in theatre. The vertex was presenting in the right occiptoanterior position at 0 station. Nivelle Barns forceps were applied and the head was delivered after three pulls, with a right mediolateral episiotomy performed. A 4.220 kg active term male baby was born and the placenta was removed manually. The patient sustained a third degree tear, which was repaired alongside the episiotomy. She lost 1,500 ml of blood and was started on oral iron, alongside antibiotics and laxatives for the third degree tear. The patient recovered well and had no problems with anal incontinence when seen for postnatal check. She was keen on vaginal delivery in a subsequent pregnancy.