TOLAC/VBAC Flashcards
Advantage of VBAC
- Avoid major abd surgery
- Lower rates of hemorrhage, thromboembolism, and infection
- a shorter recovery period than women who have an elective repeat cesarean delivery
- Avoid consequence of multiple CS (eg, hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as placenta previa and placenta accreta)
Maternal risks of TOLAC
Endometritis, blood transfusion, hysterectomy, uterine rupture, maternal death, infection, surgical injury
Neonatal risks of TOLAC
Antepartum/intrapartum stillbirth; hypoxic ischemic encephalopathy; NICU admission; respiratory morbidity; transient tachypnea
Factors that decrease success rate of TOLAC
- increasing maternal age
- high body mass index
- high birth weight
- advanced gestational age at delivery (more than 40 weeks)
- a shorter interdelivery interval (less than 19 months)
- the presence of preeclampsia at the time of delivery
Induction and augmentation of labor
Augmentation or induction of labor was associated with an increased risk of uterine rupture when compared with spontaneous labor
- Mechanical dilation and transcervical catheters, such interventions may be an option for TOLAC candidates with an unfavorable cervix.
- Prostaglandin E1, misoprostol, should not be used for cervical ripening or labor induction.
- Because data are limited, it is difficult to make definitive recommendations regarding the use of prostaglandin E2.
- Given that the results of these studies vary and that the absolute magnitude of the risk reported in these studies is small, oxytocin augmentation may be used in women attempting TOLAC.
- However, studies have not identified a clear threshold for rupture, and an upper limit for oxytocin dosage with TOLAC has not been established
Risk of uterine rupture after one prior low-transverse uterine incision
0.5–0.9%
TOLAC contraindications
those at high risk of uterine rupture: a previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery)
those in whom vaginal delivery is otherwise contraindicated (eg, those with placenta previa)
When you use a TOLAC calculator, what % should recommend against TOLAC
- No universally agreed upon discriminatory point. 60%
women with at least a 60–70% likelihood of achieving a VBAC who attempt TOLAC experience the same or less maternal morbidity than women who have an elective repeat cesarean delivery. Conversely, women who have a lower than 60% probability of achieving a VBAC who attempt TOLAC are more likely to experience morbidity than women who have an elective repeat cesarean delivery
TOLAC for women with more than one cesarean delivery?
Yes for 2 LTCS
- Some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was small.
- The likelihood of achieving VBAC appears to be similar for women with one previous cesarean delivery and women with more than one previous cesarean delivery.
Macrosomia and TOLAC?
Suspected macrosomia alone should not preclude offering TOLAC.
- A lower likelihood of VBAC.
- H/o CS for shoulder dystocia also has a lower likelihood of VBAC
> = 40wk and TOLAC?
Gestational age greater than 40 weeks alone should not preclude TOLAC.
- A lower likelihood of VBAC.
Previous Low-Vertical Incision and TOLAC?
Yes
Unknown Type of Prior Uterine Incision and TOLAC?
Yes, unless there is a high clinical suspicion of a previous classical uterine incision such as cesarean delivery performed at an extremely preterm gestational age.
Twin gestation and TOLAC?
Yes.
Women with one previous cesarean delivery with a low-transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, are considered candidates for TOLAC
Obesity and TOLAC
Maybe.
- A high BMI alone should not be considered an absolute contraindication to TOLAC.
- Depending on their other characteristics (eg, having had a prior vaginal delivery), and their care should be individualized.
ECV and TOLAC
Not contraindicated.
- Similar ECV success rate in women with and without a prior cesarean delivery
Epidural and TOLAC?
Epidural analgesia is not a risk factors for failed TOLAC; may be used as part of TOLAC; should not be considered necessary; should not be expected to mask signs or symptoms of uterine rupture.
Labor curve for TOLAC
- Women with a prior cesarean delivery and no prior vaginal delivery had labor patterns similar to nulliparous women
- Women with a prior cesarean as well as a prior vaginal delivery had labor patterns similar to multiparous women
How to diagnose uterine rupture? Acute signs and symptoms of uterine rupture?
- Use continuous electronic fetal monitoring.
- IUPC and FSE are not superior to external
- fetal heart rate abnormality (70%)
- Fetal bradycardia
- Increased uterine contractions
- Vaginal bleeding, loss of fetal station
- New onset of intense uterine pain
Risk of uterine rupture recurrence if the first uterine rupture happened at lower segment?
Risk of uterine rupture recurrence if the first uterine rupture happened at upper segment?
When should repeat cesarean delivery
be performed for women with a previous uterine rupture?
If the site of the ruptured scar is confined to the lower segment of the uterus, the rate of repeat rupture or dehiscence in labor is 6%.
If the scar includes the upper segment of the uterus, the repeat rupture rate is reported to be as high as 32%.
Between 36 0/7 weeks and 37 0/7 weeks
IUFD and TOLAC?
D&E is fine.
Labor induction with transcervical Foley catheter, prostaglandins, and/or oxytocin are all fine
