VBAC

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Vaginal Birth After Cesarean

• Kirsten Vitrikas, MAJ, USAF, MC
• Scott AFB
• SLU Family Medicine Residency

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Objectives

• Review incidence of C-section and trends
• Discuss favorable and unfavorable factors for
  successful VBAC
• Discuss risks and benefits of VBAC
• Recommendations on appropriate candidates for VBAC

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Primary Cesarean Rate and Rate of Vaginal Birth
after Previous Cesarean Delivery (VBAC) in the
United States, 19892004, and Data for Total
Cesarean Rate, 19892005
NEJM Mar 2007
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ACOG Statement
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.
ACOG Practice Bulletin No. 54, July 2004
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AAFP Statement
TOLAC should not be restricted only to facilities
with available surgical teams present throughout
labor since there is no evidence that these
additional resources result in improved outcomes.
At the same time, it is clinically appropriate
that a management plan for uterine rupture and
other potential emergencies requiring rapid
cesarean section should be documented for each
woman undergoing TOLAC.
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National Vital Statistics Report

• In 2003, rate of c/s for primips 27.1
• Repeat rate 89.4, for low risk women 88.7
• Healthy People 2010 target rates
• Primary 15
• Repeat 63
• Rates have incr from 1996-2003
• Only 11 of low risk women have VBAC

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NVSS Vol. 54, No. 4
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NVSS Vol. 54, No. 4
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AHRQ Questions

• Frequency of vaginal delivery
• How accurate are risk assessment tools?
• What are relative harms?
• What is incidence of uterine rupture and can we
  prevent major MM?
• What are the health status and QOL issues?
• What factors influence patient satisfaction w/
  childbirth experience
• What are the economic influences?

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AHRQ summary

• In 2000, 22.9 deliveries by C-section
• Primary 16
• VBAC rates vary by region
• 2001 survey by AAFP
• 29.8 of FPs do ob

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Success Rates

• VBAC success 60-80 (LOE II-2)
• More likely to choose in tertiary hospital
• Spontaneous labor-80 vag delivery
• Oxytocin use-68 vag delivery
• Cervical ripening or induction-51 vag delivery

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Positive Factors

• Age lt40 years
• Prior vaginal delivery (esp VBAC)
• Favorable cervical factors
• Spontaneous labor
• Nonrecurrent indication
• More than 6 months since last delivery and this
  pregnancy

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Negative Factors

• Incr number of prior Cesarean deliveries
• EGA gt40 wks
• Birth weight gt4000g
• Induction or augmentation of labor
• Uterine closure

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Risk Assessment Tools

• Predictive tools have fair to good quality
  evidence
• Imaging modalities ineffective (LOE I)

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Flamm, 1997
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Benefits of VBAC

• Shorter stay
• Less blood loss
• Decr risk of infection
• Fewer thromboembolic events
• Decreased risk of multiple surgeries
• Less neonatal respiratory complications
• Cost-effective and higher quality of life if
  likelihood vag delivery gt76

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Complications of VBAC

• Rates of uterine rupture 24-52/10,000
• Does not incl induced (77/10,000)
• May lead to hysterectomy, transfusions, operative
  injury
• Rates of perinatal death 1.5/10,000
• Severe neonatal neuro injury
• Maternal death 0.02/1000 TOL

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Signs of uterine rupture

• Fetal heart rate deceleration or bradycardia
• Loss of station
• Palpable fetal parts in abdomen
• Abdominal pain or uterine tenderness
• Vaginal bleeding
• Hypovolemia
• Cessation of contractions

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Lydon-Rochelle, NEJM 2001
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Higher risk

• 2 previous sections
• Rates of rupture 1-3.7
• Less if prior vag delivery
• Macrosomia (BW gt4000-4500g)
• 60-90 success, less if no prior vag del
• gt40 wks, decr success, but no more likely to
  rupture
• Unknown scar type

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Contraindications

• Previous classical incision
• Rupture rate 4-9 and may occur prior to labor
• Previous rupture
• Previous uterine surgery
• Medical or obstetrical indication precluding
  vaginal delivery (eg previa)
• Staffing issues

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Candidates for VBAC

• One prior low-transverse section
• Adequate pelvis
• No previous rupture or other uterine scar
• Physician immediately available through active
  labor
• Available personnel for emergent delivery
• Previous low vertical no higher risk
• No evidence for incr risk w/ twins

ACOG PB No. 54, July 2004
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Recommendations

• Women with one prior C/S should be offered a
  trial of labor (Level A)
• Individual counseling
• NO prostaglandins (Level B)
• Epidurals ok
• Close attention to labor progress and FHR
  monitoring
• Exploration of scar after delivery controversial

SORT
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Bibliography

• Gabbe et. Al 4th edition, pp 570-585
• AHRQ-Vaginal Birth after Cesarean (VBAC)Evidence
  Report/Technology Assessment, No. 71
• National Vital Statistics Report Vol. 54, No. 4
• Deutchman M, Roberts R. VBAC Protecting
  Patients, Defending Doctors Editorial. Am Fam
  Phy 200367931
• Lydon-Rochelle et. al. Risk of Uterine Rupture
  During Labor Among Women With A Prior Cesarean
  Delivery. NEJM 2001 3451
• ACOG Practice Bulletin No. 54 Vaginal birth
  after previous Cesarean. Obstet Gynecol 2004
  104203
• Wall E, et. al. AAFP Policy on TOLAC March 2005
• Flamm B, et. al. Vaginal birth after Cesarean
  delivery an admission scoring system. Obstet
  Gynecol, 1997 90(6)907-910