Академический Документы
Профессиональный Документы
Культура Документы
(VBAC)
Presenter
Dr. Hem Nath Subedi
Resident, OBGYN
COMS-TH, Bharatpur
Few issues in modern obstetrics have been as controversial
as management of the woman who has had a prior cesarean
delivery.1
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
2
In 1920s the technique of low transverse uterine incision was
introduced by Kerr.1
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 3
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After
4
Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Pregnant women with a previous cesarean section
can deliver in one of the following ways.2
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities 5
Press,2011;pp 266-276
Maternal risk of TOLAC
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-
276 6
Maternal risk of TOLAC
Risk associated with failed TOLAC.
The major determinant of morbidity associated with a decision for
TOLAC is whether the attempt is successful.2
In a study from Nigeria, failed VBAC was associated with higher
incidence of chorioamnionitis, PPH, Blood transfusion, uterine
rupture, hysterectomy and composite major neonatal morbidities.2
The risk factors which predicted failure were (obri et al 2010).2
Younger age
Lack of previous vaginal delivery
Induction of labour
Fetal weight>4kg
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
7
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Risk of TOLAC to fetus/neonate
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
8
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
9
Candidate for a TOLAC
Some Factors for Consideration in Selection of Candidates for
Vaginal Birth after Cesarean Delivery (VBAC)
One previous prior low-transverse cesarean delivery
Clinically adequate pelvis
No other uterine scars or previous rupture
Physician immediately available throughout active labor capable of
monitoring labor and performing an emergency cesarean delivery
Availability of anesthesia and personnel for emergency cesarean delivery
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
11
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
12
Factors influencing success of VBAC
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 13
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
14
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Prior uterine rupture
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 17
Number of prior cesarean incisions
It also seems logical that the risk of uterine rupture would
increase with the number of previous cesarean deliveries.1
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
19
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Indication for prior cesarean delivery
The success rate for a trial of labor depends to some extent on
the indication for the previous cesarean delivery. 1
In a large series reported by Wing and Paul (1999), 91 percent
of women whose first cesarean delivery was for breech
presentation subsequently delivered vaginally.1
If fetal distress was the original indication, the success rate
was 84 percent.1
Prior dystocia is an important predictor of vaginal delivery
after prior cesarean. In more than 1900 women, Peaceman and
associates (2006) found that those with dystocia as the original
indication had a significantly lower success rate compared
with those with other indications54 versus 67 percent,
respectively.1
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
20
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Fetal size
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 21
Multifetal gestation
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 23
Antenatal care
Identify ,at the first antenatal visit all women who have had a
previous cesarean section or have a uterine scar, a senior
consultant should assess them.2
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
24
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Factors to note at booking visit include
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
25
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Antenatal counseling
Women with a prior history of one uncomplicated LSCS , in an
otherwise uncomplicated pregnancy at term, with no contraindication
to vaginal birth, should be able to discuss the option of planned
VBAC and the alternative on an elective repeat cesarean.2
The antenatal counseling of women with a prior cesarean birth should
be documented in the notes . A patient information leaflet should be
provide with the consultation.2
A final decision for mode of birth should be agreed between the
woman and her obstetrician before the expected/planned delivery
date, ideally by 36weeks of gestation (flamm et al 1990).2
Placenta previa/accreta should be excluded with USG. Identifying and
treating anemia early on is important in these women.
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After
Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 26
If decision is made for TOLAC ,the woman
should be advised:
To present to the obstetric unit early in labour or if there is
SROM occurs.2
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth After
28
Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Continuous fetal monitoring
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576 2)Vaginal birth
After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276 29
Partogram for progress of labour
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 30
266-276
Analgesia
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
31
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266-276
Early diagnosis of uterine rupture
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities Press,2011;pp 266- 32
276
Delivery
The length of the second stage should not exceed 2 hrs. one
hour to allow passive descent, but no more than one hour for
active pushing (or 30 minutes if the woman has had a prior
vaginal delivery).2
Assisted delivery ,in the presence of a prior uterine scar,
should ideally only be performed by an experienced
consultant. This should be in the operating theatre with
provision for immediate cesarean section.2
Excessive vaginal bleeding or signs of hypovolemia are
potential signs of uterine rupture and should prompt complete
evaluation of the genital tract (cahill etal 2005).2
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities
33
Press,2011;pp 266-276
Role of induction and augmentation of labour in
VBAC
Women with a previous cesarean should be informed of the
two to three fold increased risk of uterine rupture and around
1.5 fold increased risk of cesarean section in induced labours
compared with spontaneous labour.2
Lydon-Rochelle and associates (2001) performed a
retrospective population-based study. They found that
induction of labor with prostaglandins for VBAC increased the
uterine rupture risk more than 15-fold compared with elective
repeat cesarean delivery.1
1)prior cesarean delivery In: William's obstetrics, 23rd edition, New York, Mc Graw Hill, 2010;pp 565-576
2)Vaginal birth After Cesarean Delivery In: The management of labour, 3rd edition, India Universities
Press,2011;pp 266-276
34
Thank you
35