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Trial of Labor After Previous

Cesarean DeliveryTOLAC

The term trial of labor refers to a trial of labor in women who

have

had a previous cesarean delivery, regardless of the outcome.

TOLAC MAY LEAD TO SUCCESFUL VBAC


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ACOG # 115 2010

Validate/Reference well performed studies & present

a range of data (+/-) emphasizing that it may be

reasonable to expand the CANDIDATE POOL.

Extreme caution should STILL be exercised whenconsidering additional factors @ term which may

influence the success or failure of VBAC

THE MOST CLINICALLY USEFUL INFORMATION IN THE

NEW BULLETIN

TOLAC COUNSELING CALCULATOR

MORTALITY /MORBIDITY % tge TABLES


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The American College of Obstetricians and Gynecologists

guidelines for identifying women who are potential candidates

for TOLAC NOW include the following:

WHO ARE NEW TOLAC CANDIDATES TWO previous low transverse uterine incisions Ok Twins Ok ECV Ok EGA > 40 weeks Ok One Low vertical Ok

Suspected Macrosomia alone Ok

Informed induction Ok however NO prostaglandins

followed by oxytocin. ( Foley bulb followed by pitocin )

Undocumented scar with out history suggesting classical c/s

ACOG PRACTICE BULLETIN AUGUST Number 115, 2010


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Contraindications for VBAC Prior classical or T-shaped uterine incision or extensive

transfundal uterine surgery (eg, myomectomy)

Previous uterine rupture (the frequency of repeat rupturevaries from 6 to 32 percent, respectively if the lower uterinesegment or the upper segment was the site of the initialrupture)

No Cytotec

Medical or obstetrical complications that preclude vaginal birth(eg, placenta previa)

Inability to immediately perform emergency cesarean deliverydue to factors related to the facility, surgeon, anesthesia, ornursing staff

Two or more prior uterine scars and no prior vaginaldeliveries. 2010 REMOVED two previous c/s andremained silent regarding previous vaginal delivery

ACOG VBAC Bulletin # 54JULY 2004/ 2010 #115


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Uterine Rupture

By Incision Location

The rate of rupture reported by incision

location is:

Classical (4 to 9 %)

T-shaped (4 to 9 %)

Low vertical (1 to 7 %)

1 Low transverse ( 0.7 to 0.9 %)2 Low transverse ( 0.9-1.8 % )


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2 previous C/S

Candidates but Counsel Carefully

Two large studies referenced by ACOG, with sufficient size to control for

confounding variables, reported on the risks for women with two previous

cesarean deliveries undergoing TOLAC.

One study found no increased risk of uterine rupture (0.9% versus 0.7%) in

women with one versus multiple prior cesarean deliveries , whereas the

other noted a risk of Uterine Rupturethat increased from 0.9% to 1.8% (

2X )in women with one versus two prior cesarean deliveries

Both studies reported 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 relatively small (eg, 2.1%

versus 3.2%) composite major morbidity in one study


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2 PREVIOUS C/S

ACOG 2010

The chance ofachieving VBAC appears to be similarfor women with one or more than one cesareandelivery.

Given the overall data, it is reasonable to consider

women with two previous low transverse cesareandeliveries to be candidates for TOLAC

Do Not forget to Counsel based on the

combination of other factors that affect theprobability of achieving a successful VBAC.


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Maternal Factors Associated

VBAC SUCCESS Young maternal age

Increased height

Body mass index


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TOLAC/VBAC SUCCESS COUNSELING

CALCULATOR 2010 ACOG A model was developed specifically for women

undergoing TOLAC at term with one prior low

transverse cesarean delivery incision, singletonpregnancy, and cephalic fetal presentation.

This model may have utility for patient

education and counseling for those consideringTOLAC at term


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VAGINAL BIRTH AFTER CESAREAN

Height & weight optional; enter them to automatically calculate BMI

Maternal age

Height (range 54-80 in.)

Weight (range 80-310 lb.)

Body mass index (BMI, range

15-75)

African-American?

Hispanic?

Any previous vaginal delivery?

Any vaginal delivery sincelast cesarean?

Indication for prior cesarean

of arrest

of dilation or descent?


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SAMPLE PATIENT

5 FOOT 3 INCHES

225 LBS

HISPANIC

NO PREVIOUS VAGINAL DELIVERY

PREVIOUS C/S FOR CPD

Predicted chance of vaginal birth aftercesarean: 24.5% 95% CI: [21.3%, 28.1%]


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CONSIDER THE RESULTS

Consider additional Information

It is designed for educational use and is based on a

population of women who received care at the

hospitals within the MFMU Network. Responsibility

for its correct application is accepted by the enduser.

"Development of a nomogram for prediction of

vaginal birth after cesarean delivery," Obstetrics andGynecology, volume 109, pages 806-12, 2007.


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ACOG/TOLAC CALCULATOR

ACOG 2010

Although there is no universally agreed ondiscriminatory point, evidence suggests thatwomen with at least

6070% chance of VBAC Have equal or less maternal morbidity when they

undergo TOLAC than women undergoing elective

repeat cesarean delivery


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ACOG/TOLAC CALCULATOR

ACOG 2010

Less than or Equal to 60%

probability TOLAC RISK outweighthe potential benefit Failed VBAC is associated with a greater

chance of NEONATAL AND MATERNALMORBIDITY than woman undergoing elective

repeat cesarean delivery


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The MFMU Cesarean Registry:Prospective study with > 14,500 vbac attempts

The overall VBAC success rate in obesewomen (BMI > or = 30) was lower (68.4%)than in non obese women (79.6%) (P < .001)

When combined with induction and lack ofprevious vaginal delivery, successful VBACoccurred in only 44.2% of cases.

Am J Obstet Gynecol 2005 Sep;193(3 Pt 2):1016-23


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Success for VBAC by History

PREVIOUS VAGINAL DELIVERY

Yes / 85% success No / 60% success

PREVIOUS VBAC DELIVERY

Yes / 85% success No / 65% success

CERVIX 4 CM ON ADMISSION

Yes / 85 % success No / 65% success

SPONTANEOUS LABOR 80% success

Am J Obstet Gynecol 2005; 193:1016


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Success for VBAC by history

Previous non recurring indication 75-85 %

All pts with DYSTOCIA as indication 50-80%

Latent phase C/S (4cm or less) 80%Active phase C/S ( 5 to 9 cm ) 70%

Second stage C/S (10 & pushing) 10%

ACOG VBAC BULLETIN # 54 2004


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Increase BMI > 39 = Increased risk

A BMI > 39 was associated with greater compositematernal morbidity and neonatal injury comparedwith elective repeat cesarean delivery

Increasing BMI was directly associated with failedtrial of labor after previous cesarean delivery

BMI > 39 TOLAC WAS ASSOCIATED WITH

5 X risk of uterine rupture (2.1% vs 0.4%),

5 X risk of neonatal injury (1.1% vs 0.2%) 2 X risk of Maternal Morbidity (7.2% versus 3.8%)

Obstet Gynecol. 2006 Jul;108(1):125-33 MFMU


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VBAC Safety and Success

AT OR

Beyond 40 weeks of gestation

There is a 4% increased risk for a failed VBAC

@ 35 % @ 41 weeks vs 31 % @ 40 weeks

~ 65 % successful VBAC @ 41 weeks

The risk of overall maternal morbidity IS not

clinically or statistically significant when

comparing after 41 vs 40 weeks (2.7% @ 41

weeks compared with 2.1% @ 40 0/7 weeks).

Obstet Gynecol. 2005 Oct;106(4):700-6


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40 WEEKS OR GREATER

Although chances of success may be lower( 4%) in

more advanced gestations, gestational age of greater

than 40 weeks alone should not preclude TOLAC.

Use calculator to help you decide Be cautious and include OTHER PERTINENT risk

factors for VBAC failure or increased risk for uterine

rupture with TOLAC in this situation such as

Interdelivery interval, EFW ( > 3600 grams) , & Bishop

score, Previous C/S indication,

ACOG 2010 #115


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4000 GRAMS MACROSOMIA

Some limited evidence also suggests that the uterine

rupture rate is increased (relative risk 2.3, P


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TWINS

Women with twin gestations had a similar chance of achieving

VBAC as women with singleton gestations and did not incur

any greater risk of uterine rupture or maternal or perinatal

morbidity.

Women with one previous cesarean delivery with a low

transverse incision, who are otherwise appropriate candidates

for twin vaginal delivery, may be considered candidates for

TOLAC.


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INDUCTION/AUGMENTATION

Induced labor is less likely to result in VBAC than

spontaneous labor, ESPECIALLY with an unfavorable cervix.

Therefore, selecting women most likely to give birth vaginally

while avoiding sequential use of prostaglandins and

oxytocin appears to have the lowest risks of uterine rupture.

The varying outcomes of available studies and small absolute

magnitude of the risk reported in those studies support that

oxytocinaugmentation may be used in patients undergoing

TOLAC. 1% risk of rupture with oxytocin augmentation

Induction utilizing mechanical dilation ( Foley Bulb distended

to 40 ml more effective or @ least as effective as Cytotec in

RCT) may be an option for TOLAC candidates with an

unfavorable cervix.


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COUNSELING RISK OF

UTERINE RUPTURE

Spontaneous labor 0.9% 1 c/s vs 1.8% for 2

Induced TOLAC 1% - 2.4%

Pitocin Augmented 1%

Am J Obstet Gynecol 1999;181:882

N Engl J Med 2004;351:2581 9

N Engl J Med. 2001 Jul 5;345(1):3-8.

ACOG Number 115, August 2010


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IS THERE A role of UTERINE CLOSURE

in the risk of uterine rupture

NOT CONSISTENTLY DEMONSTARTED AS A RISK FACTOR ANDNOT INCLUDED BY ACOG AS A RISK FACTOR

Prior single-layer closure may be associated with a

two fold or higher risk of uterine rupture comparedwith double-layer closure. Single-layer closure should

be avoided in women who could contemplate future

vaginal birth after cesarean delivery.

Bujold E Obstet Gynecol. 2010 Jul;116(1):43-50

Bujold E Am J Obstet Gynecol. 2002;186(6):1326-30


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Controversy Regarding

Closure of the Uterus

Only one Author (Bujold E) has demonstrated anincreased risk of uterine rupture with single vs two layer

closure in two separate retrospective studies.

No proven physiologic/biologic models. Inclusion ofendometrium in animal studies may be associated with

adenomyosis and interfere with scar formation ; However

Never been demonstrated to effect scar integrity.

Hypoxia and/Or vascular occlusion may result in poor tissue

healing? Locking vs Running uterine closure? Or Multiple

hemostatic figure of 8 sutures? Never been demonstrated to

effect scar integrity .

Sh t I t d li I t l


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Short Interdelivery IntervalTime elapsed from previous delivery date to

current TOLAC

Multiple studies have demonstrated that an

Interdelivery interval < or = to 18 months may be

associated with a two fold or higher risk of uterine

rupture during TOLAC. Furthermore it appears that ashorter Interdelivery interval is associated with a

greater than two fold risk of rupture.

Obstet Gynecol. 2010 May;115(5):1003-6Obstet Gynecol. 2007 Nov;110(5):1075-82.

Am J Obstet Gynecol. 2002 ;187(5):1199-202

Obstet Gynecol. 2001 Feb;97(2):175-7

Am J Obstet Gynecol 2000;183:1180

1183


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If Uterine Rupture Occurs with

Immediately Available Team

Risk of HIE 10-11% @ worse case estimate

(95% confidence interval, 1.810.6%)

Neonatal death ~ 5% @ worse case estimate(95% CI, 04.2% )

Maternal risk of ~ 10 % for Transfusion

5% risk for TAH ;

30 % for TAH with Catastrophic Rupture


N Engl J Med 2001;345:3-8


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Maternal Risks ERCD (%) TOLAC (%)

One CD Two CDs

Endometritis 1.52.1 2.9 3.1

Operative injury 0.42.6 0.4 0.4

Blood transfusion 11.4 0.71.7 3.2

Hysterectomy 00.4 0.20.5 0.6

Uterine rupture 0.40.5 0.70.9 0.91.8

Maternal death 0.020.04 0.02 0



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Neonatal risk

Short term respiratory transitional needs ~ 2 x as high

with ERCD vs successful VBAC

Hyperbilirubinemia ~ 2 x as high with ERCD vs

successful VBAC

Neonatal morbidity is higher in the setting of a failed

TOLAC than with successful VBAC

( therefore < 60% success not recommended for TOLAC) Perinatal mortality is higher( includes stillbirth) with TOLAC

vs ERCD ; however the absolute risk is ~ 1/10 of 1%ACOG Number 115, August 2010

N Engl J Med 2004;351:25819


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Neonatal Risks ERCD (%) TOLAC (%)

IUFD 3738 weeks 0.08 0.38

IUFD 39 weeks or greater 0.01 0.16

HIE 0013 0.08

Neonatal death 0.05 0.08 NS

Perinatal death 0.01 0.13 HYPOXIA

Neonatal admission 6.0 6.6 NS

Respiratory morbidity 1

5 0.1

1.8

Transient tachypnea 6.2 3.5

Hyperbilirubinemia 5.8 2.2


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DOCUMENTATION MANDATORY

Documentation of counseling and the management plan

should be included in the medical record.

Potential benefits and risks( % ) of both TOLAC and elective

repeat cesarean delivery should be discussed and

documented.

The VBAC SUCCESS CALCULATOR AND MATERNAL /NEONATAL

RISK TABLES provided by ACOG facilitate a STANDARDIZED

discussion that is patient specific and ENDORSED by ACOG.

After counseling, the ultimate decision to undergo TOLAC or

a repeat cesarean delivery should be made by the patient in

consultation with her healthcare provider.

Dr Montgomery Recommends


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Dr Montgomery Recommends DOCUMENT COUNSELING WIH QUOTED RISK/BENEFIT % tges

TOLAC CALCULATOR : No < 60 /60-69 Offer/ 70 or > Recommend

Additionally consider interdelivery interval during antenatal calculation

DO RECOMMEND For a patient who has requested TOLAC a scheduledrepeat cesarean section by 41 0/7 weeks with success calculated @ 70%For a patient who has requested TOLAC a scheduled repeat cesareansection by 40 0/7 weeks with success calculated @ < 70%

REMEMBER EFW & modified Bishop Score as you approach 38 weeks

Thoroughly counsel about induction or augmentation taking into accountadditional factors associated with failure and/or increased risk.

DO RECOMMEND SCHEDULED REPEAT CESAREAN SECTION @ 39 WEEKSFOR PATIENTS WHO DECLINE TOLAC; Due to the documented increasedrisk of IUFD after 39 weeks.

DO NOT recommend TOLAC for patients with a history of failure ofdescent (previously dilated to 10 cm) >/= to 85 % will have a failed VBACSchedule C/S @ 39 0/7 weeks for these patients.

DO NOT recommend TOLAC For patients with a BMI of 39 or greater.Schedule C/S @ 39 0/7 weeks for these patients.

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