Vag Delivery Plans foiled by a .........Fibroid

My preceptory and I saw a 34 year old G2 P-O A-1, 36 weeker during a routine OB appointment. This patient had a large fibroid (confirmed via U/S) located in the lower uterine segment, in lay terms-very near her cervix. It was interesting to learn more about fibroids and the problems they can potentially cause throughout a pregnancy during this patient's visit. The patient offered no complaints with the exception of feeling minor lower abdominal pain, most likely attributed to round ligament stretching. She confirmed fetal movement and an ultrasound revealed normal fetal growth for gestational age. Although she had hoped for a vaginal delivery, my preceptor explained the risks that this fibroid posed to such a delivery method. A vag-delivery could be complicated by shoulder dystocia, labor dystocia, and postpartum hemorrhage. My preceptor then proceeded to explain to the patient that a VBAC incision may not be possible because the fibroid is located where a low transverse incision is usually performed. The only, and perhaps the best option available to this patient involved making a vertical incision through the contractile portion of the uterus. However, this option is not without risk; for if the body of the uterus cannot contract properly, the risk for post-partum hemorrhage increases. The patient agreed to a c-section (vertical incision) and was aware of the reasons why this method was best for her and her baby. She did ask why the fibroid could not be conveniently removed after the c-section-to this inquiry my preceptor responded that performing a myomectomy after a c-section can really increases the risk for massive hemorrhage since a gravida uterus is highly vascular. At the end of the visit, the patient seemed very satisfied with the the information that was provided to her. I could tell that she may have been feeling a little down after learning that a vag delivery was not the best option. But as she was leaving she mentioned that whatever method is best for her baby is the route she chooses.

greg b