Vaginal Birth after Cesarean

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A trial of vaginal birth after a previous cesarean delivery (VBAC) is an accepted method of delivery for most women with a prior low-transverse cesarean delivery. Factors that increase morbidity in VBAC should be understood so that practical decisions can be made regarding the best route of delivery for each patient. ACOG (2004) suggests the following criteria for selection of appropriate candidates: one previous cesarean delivery, adequate pelvis, no uterine scars, and immediate availability of both a physician to perform an emergency cesarean delivery and facilities and anesthesia to support an immediate cesarean delivery. Use of pros-taglandin cervical ripening is discouraged in these women because of the small increased risk of uterine rupture associated with these medications when used with a scarred uterus.

The AAFP (2005) reviewed a trial of labor after cesarean (TOLAC) and compared TOLAC with elective repeat cesarean section (ERCS) and formulated the following recommendations:

Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor; epidural anesthesia may be used for VBAC (SOR: A).

Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC (limited or inconsistent scientific evidence, SOR: B).

The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged. Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care. After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record. VBAC is contraindicated in women with a previous classic uterine incision or extensive transfundal uterine surgery (primarily consensus and expert opinion, SOR: C).

After careful patient selection, preparation, and management, 7 or 8 of 10 women with uterine scars deliver vagi-nally. The strongest predictor of the safety of VBAC is the

Transfundal Uterine Incision

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Figure 21-14 Late deceleration of fetal heart rate.

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Figure 21-14 Late deceleration of fetal heart rate.

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location of the previous uterine scar. Safety of TOLAC in women with history of one cervical low-transverse cesarean has been documented. Rupture of these incisions is low,

EVIDENCE-BASED SUMMARY

• Most women with one previous cesarean delivery with a low-transverse incision are candidates for vaginal birth after cesarean (VBAC) and should be counseled about VBAC and offered a trial of labor (SOR: A).

• Epidural anesthesia may be used for VBAC (SOR: A).

• Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC (SOR: B).

• The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged (SOR: B).

• After thorough counseling about benefits and risks of VBAC, the decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician (SOR: C).

• VBAC is contraindicated in women with a previous classic uterine incision or extensive transfundal uterine surgery (SOR: C).

Data from Wall et al., 2005.

0.5% (Pridjian, 1992). Information is insufficient to determine whether TOLAC is safe for VBAC candidates with two or more prior low-transverse cesarean sections, previous low-vertical incision, multiple gestation, breech presentation, or suspected macrosomia.

Oxytocin use and epidural anesthesia are not contrain-dicated in women attempting VBAC, although they should be used cautiously in this setting. An internal uterine pressure monitor is recommended when labor is enhanced or induced medically. The most common signs and symptoms of uterine rupture are fetal decelerations and distress, heavy vaginal bleeding, decreasing station or complete loss of the presenting part, loss of contraction intensity as documented by internal pressure monitor, uterine or pelvic pain in between contractions, and bloody urine.

Women who are most likely to have a successful VBAC are less than 40 years old, have had one prior cesarean delivery, undergo spontaneous labor, have a baby no greater than 4000 g, and had a prior cesarean section that was not for failure to progress or CPD in the active phase of labor. Based on the available data, the overall outcomes from TOLAC and ERCS are so similar that the two birthing methods appear medically equivalent. As a consequence, women's preferences for the method of delivery must be explored

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Figure 21-15 Sinusoidal fetal heart rate pattern.

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Figure 21-15 Sinusoidal fetal heart rate pattern.

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and respected throughout pregnancy and during the delivery process. Women should be encouraged to undergo a TOLAC, but they should also have the opportunity to weigh the potential harms and benefits of TOLAC versus ERCS. A decision to have a cesarean delivery should be supported.

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