1. Trial of Labor After Cesarean
Carrie Griffin DO
May 3rd, 2017

2. Objectives Review the historical course of VBAC
How to counsel patients regarding risks of TOLAC and likelihood of successful VBAC
Labor management of TOLAC and its complications
Preventing the need for a TOL

3. To start….
Marisa is a 26 yo G3 P2002 at 26 wks based on a 7 wk US who is interested in TOLAC

4. Brief History
In a 1916 article entitled “Conservatism in Obstetrics” Edward Cragin famously writes “once a Cesarean section, always a Cesarean” By the 1970s, with the advent of blood transfusions, perioperative antibiotics, a shift in surgical practice, EFM, fewer vaginal breech births and fewer instrumented deliveries led to a higher CS rate of 16.5% by 1980

5. 1984 ACOG encourages TOL
1988 ACOG states that “the concept of repeat Cesarean birth should be replaced by a specific indication for a subsequent abdominal delivery”
1996 McMahon et al study in NEJM suggests VBAC riskier than initially surmised

6. VBAC-lash
McMahon et al NEJM 1996

7. ACOG 1999 VBAC Opinion
“ 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”

8. 1996 VBAC rate was 28.3
2006 VBAC rate was 8.5 and CS rate was 31.1

9. NIH VBAC Conference 2010
Found that increase in perinatal mortality from TOLAC is “small and comparable to the perinatal mortality rate observed among laboring nulliparous women” Increased rates of placenta previa and invasive placentation in women having a third cesarean There are not enough anesthesia providers to ensure “immediate availability” to all labor & delivery units

10. NIH VBAC Conference 2010
Voiced concern about barriers to VBAC and recommended that hospitals, providers, insurers and patients collaborate to develop services and strategies to mitigate existing barriers
Asked for ACOG to revisit its immediate availability recommendation

11. ACOG 2010 Practice Bulletin
“When resources for immediate Cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic and operating room staffs.”
“Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.”

12. Which of these women is not a candidate for a TOLAC?
Woman with twin pregnancy and 1 prior CS
Vertical skin incision
BMI of 48
Classical uterine incision
Woman with a history of pre-eclampsia and 2 prior CS

13. ACOG 2010 TOLAC Eligibility
NO TOLAC IF
Classical or T incision
Extension of incision into contractile portion of uterus
Full thickness myomectomy
OK IF
1 or 2 prior LTCS
Twins with single prior LTCS
> 40 wks
Macrosomia
Prior low vertical incision
Unknown uterine scar

14. Marisa is a 26 yo G3 P2002 at 26 wks based on a 7 wk US who is interested in a TOLAC

15. Prior obstetric history
Request and review prior operative report
Counsel regarding risks and benefits of TOLAC
Understand what local hospital capabilities are
Sign TOLAC consent prenatally
Continue to readdress decision with patient if change in risk factors, when presents in labor and throughout labor process

16. Maternal Risks from ERCS vs TOLAC

17. Neonatal Risks after ERCS vs TOLAC

18. Neonatal Risk of TOLAC
Landon et al NEJM 2004 study of 17,000 + women which reviewed neonatal outcomes of HIE and death
HIE occurred in no infants whose mothers underwent ERCS and in 12 infants whose mothers had a TOLAC
7 of these 12 were following uterine rupture
2 neonatal deaths

19. Maternal Advantages Avoid major abdominal surgery
Lower rates of hemorrhage, infection
Shorter recovery time

20. Neonatal Advantages
Vaginal birth associated with less respiratory distress of the newborn, greater likelihood of early initiation of breastfeeding and skin to skin contact

21. Risks of multiple cesareans
Placenta previa
Placenta accreta
Severe adhesive disease
Bladder and bowel injury
Emergency hysterectomy

22. The best predictor of a successful VBAC is
Really, really wanting one
BMI < 30
Hispanic
Spontaneous labor
History of a prior VD

23. Predictors of Success Increased Likelihood Decreased Likelihood
Prior vaginal birth before or after CS
No prior vaginal deliveries
Admitted in active labor
Labor induction
Fetal weight < 4000 gm
Macrosomia
Prior Cesarean for nonrecurring cause (previa, breech)
Prior Cesarean for second stage arrest
BMI < 30
Obesity
Non-hispanic white
Hispanic or African-American

24. VBAC Scoring Systems 74% success rate
Individual factors usually still leave women in 60-80% success category unless she has had a prior vaginal birth
Grobman nomogram most commonly used

25. Grobman nomogram

26. Marisa scores a….
Predicted chance of VBAC: 81.9%

27. If she had not had a prior VD
Predicted VBAC now 65.1%

28. And if Marisa were not Hispanic…
Predicted VBAC success now 90.1%

29. Uterine Rupture

30. Risk Stratification for Uterine Rupture
Type of uterine incision
Multiple prior cesareans
Interval since last cesarean
# layers of uterine closure

31. Uterine Rupture Rate Based on Type of Incision
Classical Incision 4 – 9%
T or J Incision 4 – 9%
Low vertical incision %
Low transverse incision 0.2 – 1.5%

32. Risk of multiple cesareans
Landon et al study in 2006
4 year observational study of 45,000 + VBAC
0.9% rate of rupture with multiple CS
0.7% rate of rupture with 1 prior
66% successful VBAC with multiple CS
74% success rate with 1 prior
Higher risk of transfusion and hysterectomy if multiple CS

33. Cesarean Interval
Interval of < 6 months between Cesarean and conception shown to have an odds ratio of 2.66 for uterine rupture

34. Uterine Closure Technique
Mixed data but 2014 meta-analysis of 14 studies did not show a difference in uterine rupture rates between single and double uterine closures

35. Called by the junior night float resident and learn that Marisa is having contractions every 3-4 minutes and is 6 cm and being admitted for labor

36. Intrapartum Management
Type and screen all TOLAC patients
IV access
Continuous fetal monitoring
Immediate availability of surgeon, anesthesia and OR staff
Routine use of IUPC with or without oxytocin usage does not decrease uterine rupture rates

37. Which of the following should be avoided in labor induction or augmentation in TOLAC patients?
Pitocin
Foley bulb
Misoprostol
Evening primrose oil
Nipple stimulation

38. TOLAC Induction Avoid elective induction
No misoprostol – unclear if other prostaglandins carry same risk
Balloon catheters + “slow” pitocin
Continue to readdress risks & viability of successful VBAC throughout induction

39. Marisa is now 8 cm and you head in to the hospital
Marisa is now 8 cm and you head in to the hospital. When you arrive her strip looks like this:

40. Diagnosis of Uterine Rupture
Sudden and constant pain
Vaginal bleeding
Loss of uterine contractions
Elevation of presenting part
Typically however fetal distress seen first on EFM (70% of cases this is initial indication)

41. Management of Uterine Rupture
Fetal resuscitation techniques still apply including prompt delivery of fetus which may necessitate CS
Ensure adequate IV access, neonatal providers available
Some evidence that best neonatal outcomes occur if delivery occurs within 17 min of fetal distress appearing on monitor

42. Tracing improves and now has only intermittent late decels and moderate variability. Marisa is complete and pushes for 80 minutes to deliver a viable female with Apgars of 8 and 9

43. Prevention….

44. Prevention for Stage 1 of Labor
Strict adherence to definitions for AOL
Latent labor
24 hours of Pitocin after AROM
Active labor
4 hours of adequate contractions + IUPC and pit
6 hours of inadequate contractions + IUPC and pit

45. Prevention for Stage 2 of Labor
Again adherence to definitions of AOL
3 hours of pushing for primiparous
2 hours of pushing for multiparous women
Longer durations acceptable if epidural analgesia in use and if progress is being documented hourly
Manual rotation of fetal occiput for malposition
Operative vaginal delivery

46. Key Practice Points Eligible if 1 or 2 prior LTCS
Success difficult to predict but generally between 60 to 80%
Most major complications occur when TOLACs end in RCS
No misoprostol/prostaglandins; Foley/pitocin only
The practice of evidence based labor management can help prevent the primary CS