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Vaginal Birth after C-section

Vaginal Birth after C-section. Andrea Chymiy, R3 MD. History of C-section in U.S. 1916: “Once a cesarean, always a cesarean” 1970 C-section rate: 5.5% 1970’s: Advent of EFM, new medico-legal pressures, increase in diagnosis of dystocia 1988 C-section rate: 24.7%. History of VBAC.

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Vaginal Birth after C-section

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  1. Vaginal Birth after C-section Andrea Chymiy, R3 MD

  2. History of C-section in U.S. • 1916: “Once a cesarean, always a cesarean” • 1970 C-section rate: 5.5% • 1970’s: Advent of EFM, new medico-legal pressures, increase in diagnosis of dystocia • 1988 C-section rate: 24.7%

  3. History of VBAC • 1980: NIH panel begins to encourage trial of labor (TOL) for women with h/o C-section • 1981 VBAC rate: 3% • 1990: US Public Health Service propose goal of C-section rate of 15% (and VBAC rate of 35%)

  4. Early data: Pro-Trial of labor (TOL) • Rosen (1991): No significant difference in maternal mortality rate found for ERCS vs. TOL. Failed TOL results in no major risk. • Flamm (1994): TOL pts shown to have shorter hospitalizations, fewer postpartum transfusions, and fewer postpartum fevers. • Hook (1997): Infants born after TOL developed fewer neonatal respiratory problems (ie: TTN) compared to those born by elective repeat C-section (ERCS)

  5. Swing of the pendulum In the 1990’some insurance companies & managed care organizations mandated that (almost) all women with previous cesarean deliveries must undergo a trial of labor (TOL).

  6. Total C-section, primary C-section & VBAC delivery rates: United States, 1989–2000 Year Total Primary VBAC 2000 . . . . . . . . . . . . . . . . . . . . . 22.9 16.0 20.7 1999 . . . . . . . . . . . . . . . . . . . . . 22.0 15.5 23.4 1998 . . . . . . . . . . . . . . . . . . . . . 21.2 14.9 26.3 1997 . . . . . . . . . . . . . . . . . . . . . 20.8 14.6 27.4 1996 . . . . . . . . . . . . . . . . . . . 20.7 14.6 28.3 1995 . . . . . . . . . . . . . . . . . . . . . 20.8 14.7 27.5 1994 . . . . . . . . . . . . . . . . . . . . . 21.2 14.9 26.3 1993 . . . . . . . . . . . . . . . . . . . . . 21.8 15.3 24.3 1992 . . . . . . . . . . . . . . . . . . . . . 22.3 15.6 22.6 1991 . . . . . . . . . . . . . . . . . . . . . 22.6 15.9 21.3 1990 . . . . . . . . . . . . . . . . . . . . . 22.7 16.0 19.9 1989 . . . . . . . . . . . . . . . . . . . . . 22.8 16.1 18.9

  7. More recent concerns about VBAC • 1999: NEJM editorial pointed out increasing rates of uterine rupture as VBAC rates have increased • 1999: Use of Misoprostol for cervical ripening/labor induction (vs spontaneous labor) found to bring almost 30-fold increase in uterine rupture rate • 2001: Use of prostaglandins for cervical ripening/labor induction (vs spontaneous labor) found to carry 5-fold increased risk of uterine rupture

  8. Paradigm shift on C-sections • Some OB/Gyns and patients are now questioning whether vaginal births should always be the goal - Some advocate elective C-section as better in long run, with decreased rates of pelvic dysfunction and urinary & fecal incontinence

  9. New attitudes toward C-section • Extreme example: Brazil - where the C-section rate is currently around 25% in publichospitals and around 98% for women who have access to privatemedicine - Sign of status (Middle class & up) - More convenient for MDs (quicker) - MDs receive little training in difficult vaginal delivery

  10. Healthy People 2010 1. For nulliparous women at 37 weeks of gestation or greater with singleton fetuses with vertex presentation, the target c-section rate is 15.5% (In 1996 the national rate was 17.%). 2. For multiparous women with one prior LTCS delivery at 37 weeks of gestation or greater with singleton fetuses with vertex presentations, the target VBAC rate is 37% (In 1996 the national rate was 30%).

  11. Advantages of VBAC • Lower rates of maternal morbidity • Postpartum fever • Wound infection • Blood transfusion • Hysterectomy • Maternal discomfort • Length of stay • Fewer cases of neonatal respiratory distress

  12. Disadvantages of attempting VBAC • Increased rates of uterine rupture - 0.2% for ERCS vs 0.4% for TOL • Increased rates of perinatal death - 0.3% for ERCS vs 0.6% for TOL • Induction with prostaglandins or misoprostol contraindicated

  13. Uterine rupture Nonsurgical complete disruption of all uterine layers which usually leads to bleeding and extrusion of all or part of the fetal-placental unit.

  14. Risk factors for uterine rupture during TOL • Maternal age > 30 • Fetal weight > 4000 grams • Induction of labor • No previous h/o vaginal delivery

  15. Risk factors for uterine rupture during TOL • Previous C-section due to dystocia • Type of C-section • Classical incision (4 - 9%) • T-shaped incision (4 - 9%) • Low vertical incision (1 - 7%) • Low transverse incision (0.2 - 1.5%)

  16. Clinical manifestations of uterine rupture • Fetal bradycardia • Variable or late decelerations • Maternal hypotension/shock • Vaginal bleeding • Cessation of contractions • Loss of station/fetal presenting part • Abdominal pain

  17. Complications of uterine rupture • Maternal mortality very rare • Fetal morbidity/mortality more common - Fetal asphyxia occurs in 5% - Perinatal morbidity/mortality highest when fetus extruded into abdomen or when interval between bradycardia & delivery exceeded 18 minutes

  18. ACOG-approved VBAC candidates • Maximum of 2 previous LTCS • Vertex fetal presentation • No other uterine scars • No history of previous uterine rupture • Clinically adequate pelvis • Ability to perform emergency C-section

  19. Absolute contraindications to VBAC • Prior transfundal myomectomy • Prior classical or T-shaped uterine incision • Inability to perform emergency C-section

  20. Relative contraindications to VBAC (more research needed) • Unknown uterine scar (most will be LTCS) • Low-vertical uterine incision • Breech presentation • Twin gestation • Postterm pregnancy • Suspected macrosomia

  21. Success rates for attempted VBAC • 50-70% of attempted VBACs result in successful vaginal birth • Factors making VBAC success more likely: - Previous vaginal delivery - Favorable cervix/Bishop score - Spontaneous onset of labor - Breech presentation as reason for previous C-section (85% success)

  22. Induction of labor in attempted VBAC • Spontaneous labor is most successful & has lowest rate of uterine rupture • Misoprostol should never be used • Rates of rupture shown in U.W. study (2001 NEJM) differed by method of induction: • Spontaneous labor - 0.52% • Induction without prostaglandins - 0.72% • Induction with prostaglandins – 2.45%

  23. Other issues in attempted VBAC • External cephalic version probably safe • Amnioinfusion considered safe • Epidural anesthesia is considered safe • Continuous EFM recommended throughout labor • Ultrasound or MR imaging of lower uterine segment may prove helpful in predicting risk of uterine rupture

  24. Conclusions • At least 50% of attempted VBACs are successful • Absolute risk from TOL is small • Uterine rupture 0.2 – 1.5% • Hysterectomy 0.1 – 0.2% • Perinatal death 0.2%

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