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m4 obgyn > Vaginal birth after caesarean (VBAC) > Flashcards

Vaginal birth after caesarean (VBAC) Flashcards

1
Q

Terminology:
VBAC
TOLAC
ERCS

A

VBAC: Vaginal Birth After Caesarean
TOLAC: Trial of Labour After Caesarean section
ERCS: Elective Repeat Caesarean Section

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2
Q

Suitable candidates for VBAC

A
  • 1 uncomplicated lower segment transverse caesarean section
  • Otherwise uncomplicated pregnancy at term, cephalic presentation
  • No contraindication to vaginal birth
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3
Q

Contraindications to VBAC

A
  • Classical caesarean section (2-9% risk of scar rupture)
  • > 2 CS
  • Previous scar/uterine rupture
  • Prior incision (low vertical, inverted T or J)
  • Myomectomy where the uterine cavity is breached
  • Any obstetric contraindications to vaginal birth e.g. Major placenta praevia
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4
Q

Benefits of VBAC

A
  • Avoid risks of surgery
  • Decrease maternal morbidity
  • Decrease risk of VTE
  • Decrease C-sects, uterine rupture, obstetrics cx in future pregnancy
  • Early mobilisation and discharge from hospital
  • Increase likelihood of future vaginal birth
  • Patient gratification
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5
Q

Risks of VBAC

A

Common (less than 5%)
- Increase risk of endometritis
- Increase risk of requiring blood transfusions

Infrequent (0.1-1%)
- Uterine rupture (*5-7/1000 attempted VBAC)
- Hypoxic ischemic encephalopathy

Rare (<0.1%)
- Perinatal death

Others
- Increase morbidity from emergency C-sect
- Pelvic floor trauma

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6
Q

Benefits of ERCS

A
  • Planned delivery
  • Reduced risk of uterine rupture
  • Reduced risk of perinatal death
  • Reduced risk of pelvic organ prolapse
  • No risk of perineal tears
  • Option of Sterilisation
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7
Q

Risks of ERCS

A
  • Surgical morbidity and complications (VTE)
  • Need CS for future pregnancies
  • Longer hospitalisation stay or recovery
  • Small increase in neonatal respiratory morbidity when
    ERCS < 39 weeks
  • Small increase risk of placenta praevia and/or accreta in future pregnancy
  • Pelvic adhesions complicating future abdominopelvic surgery
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8
Q

Factors increasing likelihood of successful VBAC

A
  • Previous successful VBAC
    *single best predictor
  • Previous safe vaginal birth
  • Spontaneous labour
  • BMI <30
  • Age <40
  • Previous CS for non-recurrent indication eg. Malpresentation
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9
Q

Factors decreasing likelihood of successful VBAC

A
  • No previous vaginal birth
  • Previous CS for labour dystocia (65%)
  • Short inter-delivery interval after CS (<18 months from
    previous CS)
  • Induced labour (65%)
  • BMI > 30
  • Advanced maternal age
  • > 41 weeks of gestation
  • Birth weight > 4kg
  • Cervical dilatation at admission <4 cm
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10
Q

Risks of IOL in VABC

A

Uterine rupture
C-sect
Higher risk of rupture with IOL with prostaglandins

*IOL using mechanical methods is a/w lower risk of rupture

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11
Q

Intrapartum support & intervention

A
  • Suitably staffed and equipped delivery suite
  • Continuous intrapartum fetal heart rate monitoring
  • Epidural analgesia to improve patient comfort +
    benefit of providing a rapid option for anesthesia if CS is required
  • Resources for immediate caesarean section and advanced neonatal resuscitation
  • Cautious oxytocin augmentation to prevent uterine rupture
  • Careful serial cervical assessments

*Increasing requirement for pain relief in labour = possibility of an impending uterine rupture

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12
Q

Uterine rupture in VBAC

A

Early diagnosis of uterine scar rupture is necessary to
ensure expeditious laparotomy and resuscitation

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13
Q

Clinical features suggestive of uterine rupture

A

Maternal
- Lancinating pain (sudden, sharp electric shock-like sensations) between contractions
- Severe abdominal pain
- Acute onset scar tenderness
- Vaginal bleeding
- Loss of contractions
- Bandl ring: constriction between woman’s thickened upper contractile uterine segment & thinned lower uterine segment

Fetal
- Loss of fetal station
- Inability to pick up fetal heart rate at the old transducer site
- Reduce fetal movements
- Meconium stained liquor

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14
Q

CTG signs suggestive of uterine rupture

A
  • Cessation of previously efficient uterine activity
  • Fetal tachycardia
  • Sudden bradycardia
  • Recurrent decelerations
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15
Q

RFs of uterine rupture in VBAC

A
  • Previous classical caesarean section
  • Prior incisions (inverted T or J incisions, low vertical incision)
  • Induction and augmentation of labour
  • Use of prostaglandins for IOL
  • 2-3x increase if inter-pregnancy interval < 18 months
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16
Q

Best predictor of successful VBAC

A

Previous successful VBAC

17
Q

What is usually the first sign of uterine scar rupture?

A

Changes in CTG
*important to have continuous CTG monitoring

m4 obgyn (37 decks)

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