TOLAC

Question 1

List placental pathologies s/p hx of C/S

Answer 1

1) plancenta previa
2) vasa previa
3) abruption
4) accreta, increta, percreta

Question 2

uterine rupture

Answer 2

disruption of all uterine layers

Question 3

What are potential consequences of uterine rupture?

Answer 3

1) NRFHR/status
2) perinatal mortality (0.11/1000 TOLACs)
3) hemorrhage
4) hypoxic-ischemic encephalopathy
5) hysterectomy

Question 4

What is the principle risk of TOLAC?

Answer 4

uterine rupture

Question 5

What can determine the risk of uterine rupture?

Answer 5

previous incision

low transverse/low vertical = lower risk (0.5-1%)
classic/T-shaped = 4-9%

Question 6

What are other risk factors for uterine rupture?

Answer 6

1) location of previous incision
2) # of prior C/S
3) single-layer uterine closure technique
4) short (<18mo) intervals b/w pregnancies
5) induction of labor

Question 7

What should not be used to induce labor in TOLAC?

Answer 7

1) miso to ripen cervix
2) prostaglandins
3) oxytocin

Question 8

uterine dehiscence

Answer 8

occult scar separation observed at laparotomy in hx of C/S

Question 9

What can be used to screen for uterine rupture/dehiscence?

Answer 9

U/S to assess thickness of lower uterine segment

Question 10

childbirth VS motherbirth

Answer 10

sacrificing self for baby and takes no risks

VS

giving birth matters to mother; happy healthy mother = happy,healthy baby

Question 11

What is the ACOG criteria for TOLAC candidates?

Answer 11

1) 1 or 2 low transverse C/S
2) clinically adequate pelvis
3) no uterine scars or previous ruptures
4) MD immediately available t/o active labor who is capable of monitoring and performing emergency C/S

“reasonable” to offer to:

• macrosomia
• GA > 40wks
• hx low vertical incision
• unknown uterine scar type
• twins

Question 12

What are the contraindications to TOLAC?

Answer 12

1) hx classical or T-shaped incision OR extensive transfundal uterine surgery
2) previous uterine rupture
3) medical or obstetric complications that preclude vaginal delivery

Question 13

What are the 6 steps of shared decision making?

Answer 13

1) invite pt to participate
2) present options
3) provide risks/benefits
4) assist pt in evaluating options based on goals/concerns
5) facilitate deliberation and decision making
6) assist w/ implementation

Question 14

What are the risks associated w/ TOLAC?

Answer 14

1) uterine rupture
2) increased maternal morbidity w/ failed TOLAC
- blood transfusion
- endometriosis
- length of stay
3) potential risk for perinatal asphyxia w/ labor
- cord prolapse
- abruption
4) potential risk for stillborn beyond 39wks GA

Question 15

What are the risks associated w/ repeat C/S?

Answer 15

1) increased maternal morbidity compared to successful trial of labor
2) increased length of stay and recovery
3) increased risks for abnormal placentation and hemorrhage w/ subsequent C/S

Question 16

What factors may improve rate of successful TOLAC?

Answer 16

1) hx of vaginal birth (87% success rate)
2) caucasian (78%) vs non-caucasian (70%)
3) hx C/S d/t NON-RECURRING indication
4) cervical dilation >4cm
5) spontaneous labor

Question 17

recurring VS non-recurring indication

Answer 17

x

Question 18

What factors reduce the rate of successful TOLAC?

Answer 18

1) hx of labor arrest disorders
2) maternal obesity
3) age >40yo
4) maternal health morbidities
5) birth at rural/private hospital
6) single mother status
7) hx C/S d/t cephalopelvic disproportion OR failure to progress (50-67%)
8) birthweight >4000mg (60-70%)
9) cervical dilation <4cm
10) induction
11) multiple C/S
12) postterm