Transcript Vaginal Birth after Cesarean

A Component of
Obstetrical Emergency Simulation Training
Objectives & Terminology
• Objective 1: Examine the risk factors of attempting vaginal
delivery after cesarean section
• Objective 2: Be able to counsel the patient on risks
• TOLAC: Trial of Labor after Cesarean
• VBAC: Vaginal Birth after C-section
• ERCD: Elective Repeat C-section
Historical Significance and General statistics
•
Between 1970-2007: C-section rate in US rose from 5% to 31%
•
Before 1980: General rule was one prior c-section = repeat c-section in
future
“Once a cesarean, always a cesarean.”
•
Early 1990s: TOLAC recommended
•
Late 1990s: bad outcomes, case reports of fetal deaths due to uterine
rupture
•
Early 2000: VBAC rate decreased
•
2010: ACOG Practice Bulletin encourages VBAC, reaffirmed in 2013,
“Most women with one previous cesarean delivery with a lowtransverse incision are candidates for and should be counseled about
VBAC and offered TOLAC.” (1)
VBAC Rates
From US National Center for Health Statistics
From US National Center for Health Statistics
From US National Center for Health Statistics
Maternal Risks with Trial of Labor
•
Failed TOLAC: 30%
•
Maternal Hemorrhage with transfusion: 1-3%
•
Risk of Uterine Rupture:
- approximately 1% if 1 prior low transverse
- approximately 2% if prior low vertical [per NICHD MFMU, 3]
- approximately 1-12 % if prior classical C-S
- approximately 6% if prior inadvertent extension during primary c-section (2)
•
Neonatal death or neurologic injury (10% of ruptures or 1/1000 trials)
•
Maternal Infection
•
Maternal Death (rare)
Absolute risk for women undergoing
TOLAC
1/100 trials of labor  Uterine Rupture
1/10 of those ruptures  neonatal death or neurologic injury
  1/1,000 TOLACs result in neonatal death or
significant injury
(from Cunningham in Williams Obstetrics)
Composite Maternal Risks from Elective Repeat
Cesarean Delivery and Trial of Labor After Previous C-section
Maternal Risks
ERCD (%)
TOLAC (%)
One C-section
TOLAC (%)
2+ c-sections
Endometritis
1.5–2.1
2.9
3.1
Operative injury
0.42–0.6
0.4
0.4
Blood transfusion
1–1.4
0.7–1.7
3.2
Hysterectomy
0–0.4
0.2–0.5
0.6
Uterine rupture
0.4–0.5
0.7–0.9
0.9–1.8
Maternal death
0.02–0.04
0.02
0
Table taken from ACOG Practice Bulletin # 115 (2)
Bottom Line
• In hypothetical group of 100,000 women at term who undergo
TOLAC (rather than ERCD)
•
9 fewer maternal deaths
•
650 additional uterine ruptures
•
50 additional neonatal deaths
Maternal Benefits of Successful VBAC
• Decrease Bleeding
• Lower infection rate
• Shorter hospitalization and recovery period
• Less likely to have maternal operative injuries associated
with higher number c-sections
• Decreased risk of abnormal placentation
• If likelihood of success > 47% TOLAC is more cost-effective
than elective repeat Cesarean (ERCD)
Perinatal Risks of TOLAC
• Increased risk for required neonatal resuscitation
• Increased risk for intubation for meconium stained amniotic fluid
• Increased risk of neonatal sepsis [5]
• Hypoxic ischemic encephalopathy (HIE)
• Neonatal death
• No significant difference in 5 minute APGAR or NICU admissions
Who is Candidate?
•
Overall probability of VBAC 60-80% if one prior low transverse uterine incision
•
Incision Type: low transverse, low vertical
•
Unknown Uterine Scar with 1 prior C-section unless there is “high clinical suspicion of
previous classical” [1]
•
≤ 2 prior Low Transverse C-sections (Level B)
•
Twin gestations with 1 prior low transverse (Level B)
•
Vertex presentation of current pregnancy. External cephalic version is not
contraindicated.
•
Motivated patient
•
ACOG defines “good candidate” as: “woman in whom the balance of risks (low
as possible) and chances of successes (as high as possible) are acceptable to
the patient and health care provider.” (1)
Predicting Successful TOLAC:
STRONG predictors
• If prior c-section was for a non-recurring condition
(breech or non-reassuring fetal heart tones)
• History of prior vaginal delivery
• Spontaneous Labor
• Appropriate size fetus
Predicting Successful TOLAC
DECREASED Probability
• Recurrent indication for initial cesarean
Labor dystocia: Arrest of Descent or Dilation
• Low grade evidence:
– Increased Maternal Age
– Non-white ethnicity
– Gestational age > 40 weeks
– Maternal obesity
– Pre-eclampsia
– Short inter-pregnancy interval
– EFW > 4000g
Lowest Probability of Successful VBAC
• Prior c-section for failure to progress +
• No previous vaginal delivery +
• Induced labor
25
18
MFMU VBAC calculator
VAGINAL BIRTH AFTER CESAREAN
Height & weight optional; enter them to automatically calculate BMI
Maternal age
years
Height (range 54-80 in.)
in
Weight (range 80-310 lb.)
lb
Body mass index (BMI, range 15-75)
kg/m2
African-American?
Hispanic?
Any previous vaginal delivery?
Any vaginal delivery since last cesarean?
Indication for prior cesarean of arrest
of dilation or descent?
CLICK HERE for calculator based on information available at admission.
Contra-Indications
• Prior Uterine Rupture or Dehiscence (6% recurrence)
• Prior Classical Incision
• Prior T-incision on uterus
• Prior extensive transfundal uterine surgery, such as removal of
fibroids, with dissection into myometrium
• Malpresentation
• Abnormal Placentation
• 3+ prior C-sections
Induction of Labor with Prior Cesarean
•
Acceptable by ACOG standards
•
Mixed opinions on whether induction carries higher risk of failed TOLAC
compared to expectant management
•
Induction and augmentation do carry increased risk of uterine
rupture:
- Rate of rupture with Pitocin (1-1.4%)
- higher risk (1.5%) if no prior vaginal delivery [3]
- Increased risk of uterine rupture if unfavorable cervix [4]
•
There may be a dose-response relationship [7]
•
No Cytotec or other Prostaglandins!!
•
May use Foley bulb for mechanical dilation
•
IUPC is OK
Induction of Labor Study
(recent Article from Green Journal)
•
Compared induction to expectant management from 37-40 weeks
•
Induction from 37-39 weeks associated with increased risk of failed TOLAC [6]
•
Induction at 40 weeks: NO increased risk of failed TOLAC
•
Increased maternal blood transfusions with failed TOLAC
•
Induction not associated with increase in uterine rupture.
•
Induction not associated with overall increased risk of neonatal morbidity [6]
J. Lappen, Outcomes of Term Induction in Trial of Labor After Cesarean Delivery; Obstet. Gynecol., July 2015.
Signs of Uterine Rupture
(in FETUS)
•
•
•
•
Variable decelerations *
Recurring variable or late decelerations
Fetal bradycardia
Sudden FHR tracing changes
• Category 2 tracing: need to consider C-S
• No tracing is pathognomonic of rupture
• Goal: timely intervention!
Signs of Uterine Rupture
(in Patient)
•
Maternal vaginal bleeding
•
Maternal hypotension
•
Sudden or worsening abdominal pain
•
Gradual decrease in amplitude of consecutive contractions with
Toco aka “Staircase sign”
•
Shoulder pain
•
Loss of station of fetal presenting part
•
Also be mindful of labor dystocia after 7 centimeters dilation [8]
What is required?
• Patient consent
• Continuous FHR monitoring
• Adequately trained nursing staff
• OB should be “immediately” available (“in house”)
• 24 hour anesthesia presence
• OR staff/surgical team available
• Adequate blood supply
• Higher level NICU
If emergent fetal rescue indicated, every minute counts!
Holmgren C, Scott J, Porter T, et al. “Uterine Ruptures with Attempted Vaginal Birth after Cesarean
Delivery: Decision-to-Delivery Time and Neonatal Outcome.” Obstetrics & Gynecololgy. 2012; Volume
119, No. 4, April 2012: 725-731.
Professional Ethics and VBAC
• The welfare of the patient (beneficence) is central to all
considerations in the patient physician relationship
• The respect for the right of the patient to make her own
choice (autonomy) is fundamental
• The physician must not misrepresent herself through any
form of communication in an untruthful, misleading or
deceptive manner.
Informed Consent (IC)
• IC is an expression of respect for the patient
ACOG stance: “After counseling, the ultimate decision to
undergo TOLAC or repeat cesarean delivery should be made by
the patient in consultation with her health care provider.”
• Shared Decision-Making Process
• IC is a process, not a signature
Informed consent (IC)
• IC contains 2 major elements:
• Comprehension and Free Consent
– Comprehension implies that the patient has been given
adequate information
– Comprehension is necessary for freedom of consent
– Ethics in Obstetrics and Gynecology, 2nd Edition, ACOG, 2004.
Conclusion
• ACOG recommends offering TOLAC with one previous CD with low
transverse incision
• Best combination for successful VBAC is: spontaneous labor + history
of prior vaginal delivery + CD was for non-recurring condition.
• Repeat CD is safest for fetus; successful VBAC is safest for mother.
• Ultimately, the decision is made by patient
Special Thanks to:
William Cusick, MD
Chairperson, Department Ob/Gyn
Director, Maternal Fetal Medicine Services
St. Vincent’s Medical Center
Bridgeport, Connecticut
References
1. “Vaginal Birth After Cesarean Delivery.” ACOG Practice
Bulletin, Number 115, August 2010
2. “Inadvertant hysterotomy extension at cesarean delivery and
risk of uterine rupture in the next pregnancy.” Goldfarb I, Henry
D, Dumont. Am J Obstet Gynecol. 2011;204:S266.
3. Landon MB, Hauth JC, Leveno KJ, Spong “Maternal and
perinatal outcomes associated with trial of labor after prior
cesarean delivery.” National Institute of Child Health and Human
Development Maternal-Fetal Medicine Units Network. N Engl J
Med 2004; 351-2581-9.
References (continued)
4. Grobman WA, Gilbert S, Landon MB, Spong CY, Leveno,
Rouse, et al. “Outcomes of induction of labor after one prior
cesarean.” Obstet Gynecology 2007; 109: 262-9.
5. Sentilhes L, Vayssiere C, Beucher, et al. “Delivery for women
with previous cesarean: guidelines for clinical practice from the
French College of Gynecologists and Obstetricians (CNGOF)
Eur J Obstet Gynecol Reprod Biol 2013; 170:205.
References (continued)
6. Lappen J, Hackney D, Bailit. “Outcomes of Term Induction in
Trial of Labor after Cesarean Delivery.” Obstetrics &
Gynecology. 2015; Volume 126, No. 1, July 2015: 115-123.
7. Cahill AG, Waterman BM, Stamilio DM, et al. “Higher Doses
of oxytocin are associated with an unacceptably high risk for
uterine rupture in patients attempting vaginal birth after
cesarean delivery.” Am Journal Obstet Gynecology. 2008;
199:32.e1
8. Harper L, Cahill A, Roehl, et al. “The Pattern of Labor
Preceding Uterine Rupture.” Am Journal Obstet Gynecology.
2012 September; 207(3): 210.
Reference (continued)
9. Holmgren C, Scott J, Porter T, et al. “Uterine
Ruptures with Attempted Vaginal Birth after
Cesarean Delivery: Decision-to-Delivery Time and
Neonatal Outcome.” Obstetrics & Gynecololgy. 2012;
Volume 119, No. 4, April 2012: 725-731.