Vaginal Birth After Cesarean (VBAC)

1. Vaginal Birth After Cesarean (VBAC) The Changing Tide

2. What Are Hospital Policies? • About 30% of all US hospitals in US had VBAC bans prior to the recently revised guidelines by ACOG. • Many WV hospitals say they will offer VBAC but rates have dramatically decreased in WV prior to revised guidelines.

3. National Rise in Cesarean Deliveries • 1970s – Less than 5% cesarean rate • 1970 - 3% VBAC rate • 1988 – cesarean delivery rate was 25% • 1996 - 40-50% of women attempted VBAC • 2002 - few as 20% of patients with a prior cesarean delivery attempted a trial of labor

4. Trial of Labor • ACOG defines TOLAC as: • Safe and appropriate for most women with previous cesarean delivery, • Should be the woman’s choice • Appropriate for some women with 2 previous low transverse incisions. • Twin pregnancies • Unknown type of uterine scar

5. Advantages of TOLAC • Meets Maternal preference • Reduced maternal morbidity • Lower risk for hemorrhage • Lower risk for infection • Faster postpartum recovery • Avoid future risks of multiple cesarean’s • Hysterectomy • Bowel and bladder injury • Transfusion • Infection • Abnormal placenta

6. Increased chance of success Prior vaginal delivery Prior VBAC Spontaneous labor Favorable cervix Nonrecurring indication (breech, previa, herpes) Decreased chance of Success Maternal obesity Short stature Macrosomia Over 40 years Induction of labor Preterm delivery Recurring indications (CPD, failed 2nd stage, interpregnancy wt. gain, gestational age over 41 weeks, diabetes, certain race/ethnicity) TOLAC

7. Risk of Uterine Rupture • Classical - although data are limited 6% - 12% • Kronig – (low vertical) 0.8% – 1.3 % • Kerr – (low transverse) 0.3% - 1% • Two prior uterine incisions - 1.8% - 3.7% • Prior vaginal delivery - 0.2% • No prior vaginal delivery - 1.1% • Less time between deliveries – 2.5 % – 3%

8. Tipping the Scale in Favor of TOLAC • Woman desires more children

9. Managing Women in TOLAC • Acute abdominal pain • Pain persist beyond contractions • A popping sensation • Palpation of fetal parts outside the uterus upon Leopold maneuver • Repetitive or prolonged fetal health rate deceleration • High presenting part upon vaginal examination • Vaginal bleeding

11. Reasons to Consider TOLAC • No abdominal surgery • Shorter recovery period • Lower risk of infection • Less blood loss • For women planning to have more children, VBAC may help them avoid problems linked to multiple cesarean deliveries, hysterectomy. Bowel/bladder injury, placenta problems

14. World Health Organization’s Six Healthy Birth Practices to help prevent the first C-section • Let labor begin on its own. • Encourage woman to walk, move around, and change positions throughout labor. • Encourage woman to bring a loved one, friend, or doula for continuous support. • Avoid interventions that are not medically necessary. • Avoid delivery with woman on her back, • Encourage woman to follow body's urges to push. • Keep mother and infant together; it is best for mother, infant, and breast-feeding.

15. The Challenge • Educate the woman so she can make an informed decision • Help women lower her risk for a first cesarean • Find that “sweet spot” • Use medical interventions only when truly beneficial to mother and baby

16. WV Perinatal Partnership Advises • Establish TOLAC guidelines within practice and within hospital • Educate practice employees on guidelines • Educate hospital employees on guidelines • Provide complete educational materials for pregnant women at first visit • Discuss guidelines throughout prenatal visits • Utilize informed consent documents • Listen to women patients

17. Vaginal Birth After C-Section • To reorder Patient Education Pamphlets in packs of 50, please call 800-762-2264 or order online at sales.acog.org. • The American College of Obstetricians and Gynecologists409 12th Street, SWPO Box 96920Washington, DC 20090-6920