CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 55, Number 4, 10051013

r 2012, Lippincott Williams & Wilkins

The Anesthesiologists
Role During
Attempted VBAC
JOY L. HAWKINS, MD
University of Colorado School of Medicine and University of
Colorado Hospital, Aurora, Colorado
Abstract: American College of Obstetricians and Gynecologists guidelines on vaginal birth after cesarean
had both intended and unintended consequences for
anesthesiologists. Epidural analgesia continues to play
an important role in patient acceptance of a trial of
labor after prior cesarean delivery. It does not impact
the success rate of vaginal birth after cesarean and may
be a diagnostic tool when uterine rupture occurs. Preanesthesia evaluation and counseling should occur early
in the patients care. Intrapartum management includes
appropriate oral intake and close communication between anesthesiologist and obstetrician. If uterine rupture or postpartum hemorrhage occur, appropriate
algorithms should be followed.
Key words: anesthesiology, epidural analgesia, general
anesthesia, postanesthesia care unit

The Impact of American

College of Obstetricians and
Gynecologists (ACOG)
Vaginal Birth After Cesarean
(VBAC) Guidelines on
Anesthesiologists
In 1999, the ACOG changed its guidelines
on vaginal birth after cesarean delivery
(VBAC),1 and anesthesiologists were
Correspondence: Joy L. Hawkins, MD, 12631 E. 17th
Avenue, Mail Stop 8203, Aurora, CO 80045. E-mail:
joy.hawkins@ucdenver.edu
The author declares that there is nothing to disclose.
CLINICAL OBSTETRICS AND GYNECOLOGY

stunned. ACOG recommended VBAC

be attempted only in hospitals where personnel and facilities to perform cesarean
delivery were immediately available.
These were the first national specialty
guidelines related to obstetric anesthesia
that used the word immediately rather
than the more vague readily available,
and the first from another medical
specialty telling anesthesiologists how
they should provide coverage for patient
care. For some time after their initial
publication, most of the anesthesiology
community was unaware of the guidelines
because they were published in nonanesthesiology journals and discussed in obstetric forums. As anesthesiologists
became aware the guidelines existed, most
assumed they did not really apply to
anesthesia providers and that no changes
would be needed in the way they provided
coverage for labor and delivery (L&D) in
their hospitals. For many smaller
anesthesiology groups and in many rural
hospitals, that coverage was provided
from home because of low delivery volumes. Studies on outcomes associated
with attempted VBAC usually came from
academic or tertiary medical centers with
a full range of resources including
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Hawkins

immediately available medical staff, yet

most women deliver in community hospitals where in-house staffing may be very
different.
ACOG declined to define immediately available, but it was assumed by
most to mean in-house coverage while
the woman was in active labor. Many
obstetricians and anesthesiologists found
it difficult to provide that level of presence, especially for small delivery services.
Billing for availability was problematic
when anesthesia services were not actually
required, that is, the patient had a successful vaginal delivery and did not request epidural analgesia. But in 2001, the
Joint Commission on Accreditation of
Healthcare
Organizations
adopted
ACOGs recommendations, and discussion about whether ACOG could mandate how anesthesiologists practice was
no longer debatable.
An unintended consequence of the
amended guidelines was a drop in attempted VBAC when some hospitals
stopped offering a trial of labor after cesarean (TOLAC) because they could not
provide the appropriate availability of obstetricians, anesthesiologists, nursing, and
an available operating room. Medical liability insurers in some states such as
Oklahoma would no longer cover claims
resulting from TOLAC. Patients were
sometimes advised that their only option
if they preferred vaginal delivery was to
relocate to another city with a hospital that
offered VBAC. In some practices, anesthesiologists found themselves performing
many scheduled repeat cesarean deliveries
and few if any trials of labor. Anesthesiologists had difficulty determining what other activities they could do while a patient
attempting VBAC was in active labor and
still be considered immediately available.
Could they provide anesthesia for a cesarean delivery? Could they care for a patient
in the main operating room who required
surgery and anesthesia? For anesthesia
providers who lived in a small town or
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rural area, could they be at home during

a TOLAC if they lived 10 or 15 or even
30 minutes away? And if the obstetrician
was seeing patients in clinic rather than
remaining in the hospital, did that mean
the anesthesiologist did not have to be
immediately available on L&D either?
These sorts of administrative questions
had no easy answers.
ACOG appropriately maintained that
despite the implications that immediate
availability had for obstetricians and
anesthesiologists, especially in smaller
hospitals, this was first and foremost a
patient safety issue. The 2 specialties have
worked together on several versions of a
joint statement entitled Optimal Goals
for Anesthesia Care in Obstetrics that
has been approved by ACOG and by the
American Society of Anesthesiologists
(ASA) House of Delegates. The most
recent version from 2010 includes the
following statement on VBAC: Because
the risks associated with trial of labor
after cesarean delivery (TOLAC) and uterine rupture may be unpredictable, the
immediate availability of appropriate facilities and personnel (including obstetric
anesthesia, nursing personnel, and a
physician capable of monitoring labor
and performing cesarean delivery, including an emergency cesarean delivery) is
optimal. When resources for immediate
cesarean delivery are not available, patients considering TOLAC should discuss
the hospitals resources and the availability of obstetric, anesthetic, pediatric and
nursing staff with their obstetric provider;
patients should be clearly informed of the
potential increase in risk and the management alternatives. The definition of immediately available personnel and
facilities remains a local decision based
on each institutions available resources
and geographic location.2 The 2 societies
continue working together toward the
goal of optimizing patient safety during
trial of labor after previous cesarean
delivery.

Impact of ACOG Guidelines on Anesthesiologists

However cesarean delivery rates continue to rise, and reports showed that only
29% of women with 1 prior cesarean
delivery attempted labor and only 57%
of those succeeded.3 In March 2010 the
National Institutes of Health convened a
Consensus Development Conference entitled: Vaginal Birth After Cesarean: New
Insights.4 The purpose was to advance
understanding on factors that contributed
to a decline in the VBAC rate since the
mid-1990s. Anesthesiologists were participants in the presentations and debate at
the conference and in writing the document. The group concluded that women
face barriers gaining access to clinicians
and facilities offering a trial of labor, and
that lack of access may drive some women
to abandon the idea of a VBAC or to
attempt TOLAC in an unsafe setting.
They recommended that ACOG and
ASA reassess the immediately available
requirement because other obstetric complications such as abruption or umbilical
cord prolapse have comparable maternal
and fetal risk as uterine rupture, yet immediate availability is not mandated. The
30-minute rule which states that hospitals
with obstetric services must be able to
respond by starting a cesarean delivery
within 30 minutes of the decision to do so
has long been used as the standard for
obstetric emergencies, but ACOG acknowledges there are many situations
such as uterine rupture or cord prolapse
that require a much more rapid response
for optimal maternal and newborn outcome. Why should TOLAC with the possibility of uterine rupture be singled out?
The consensus document also notes that
risk stratification can be done for individual patients, estimating the potential success of VBAC. Physician and nursing
resources are limited and therefore must
be used wisely for parturients with the
greatest chance of successful VBAC. The
group expressed concern that medicallegal considerations worsen access to care
and create barriers for women desiring a

1007

trial of labor after previous cesarean

delivery.
Later that year ACOG published an
updated Practice Bulletin noting that In
addition to fulfilling a patients preference
for vaginal delivery, at an individual level
VBAC is associated with decreased maternal morbidity and a decreased risk of
complications in future pregnancies. At a
population level, VBAC also is associated
with a decrease in the overall cesarean
delivery rate.5 In addition to describing
patients who are good candidates or not
candidates for TOLAC, the guidelines
state that external cephalic version for
breech presentation is not contraindicated in a woman with a prior cesarean
delivery. But perhaps the most striking change is in the description of how
patients should be counseled before
TOLAC. The guidelines state: Respect
for patient autonomy supports the concept that patients should be allowed to
accept increased levels of risk, however,
patients should be clearly informed of
such potential increase in risk and management alternatives y. In settings where
the staff needed for emergency delivery
are not immediately available, the process
for gathering needed staff when emergencies arise should be clear, and all centers
should have a plan for managing uterine
rupture. In other words, the patient
should be allowed to accept the rare but
real risk of uterine rupture and choose
whether to proceed with TOLAC, and
anesthesiologists must be ready to respond to the need for emergency delivery
in the setting of uterine rupture. This
rapid response should be no different than
the response to other obstetric emergencies such as cord prolapse or hemorrhage.

Use of Epidural Analgesia

During TOLAC
ACOG supports the use of epidural analgesia for labor during TOLAC, noting
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Hawkins

that adequate pain relief may encourage

more women to choose a trial of labor.
The guidelines go on to say that No high
quality evidence suggests that epidural
analgesia is a causal risk factor for an
unsuccessful TOLAC. In addition, effective regional analgesia should not be expected to mask signs and symptoms of
uterine rupture, particularly because the
most common sign of rupture is fetal
heart tracing abnormalities.5 This is an
important point because in the early days
of VBAC, women were sometimes denied
access to epidural analgesia for fear it
would cover symptoms of abdominal pain
and delay diagnosis of uterine rupture. A
Canadian perinatal database review of 10
years of experience with uterine rupture
found that abnormal fetal heart rate patterns were the most common sign of rupture.6 Bleeding and pain were the other
most common manifestations, and pain
occurred even when regional anesthesia
was in use. A case-control study reviewed
36 cases of uterine rupture that required
laparotomy.7 An abnormal fetal heart
rate pattern, specifically bradycardia,
was the most common diagnostic presenting sign, but rupture was also associated
with abdominal pain, vaginal bleeding,
loss of fetal station, and a palpable uterine
defect. Uterine rupture was associated
with higher rates of regional anesthesia,
which the authors speculate could be confounded by the increased rates of abdominal pain. One study found a relationship
between increasing need for analgesia as
measured by epidural top-up doses and
the risk of uterine rupture.8 They found
evidence of increasing epidural dosing in
the last 90 minutes of labor in women who
experienced a uterine rupture. There was
a dose-response relationship between the
number of epidural doses and uterine
rupture risk: 1 dose and hazard ratio 2.8,
2 doses and hazard ratio 3.1, 3 doses and
hazard ratio 6.7, and Z4 doses and hazard ratio 8.1. They conclude that epidural
analgesia does not mask uterine rupture
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and that escalating dosing requirements

can be used as an objective clinical sign of
impending uterine rupture.
Epidural analgesia does not affect the
success rate of attempted VBAC. A 4-year
prospective observational study of women undergoing TOLAC by the MaternalFetal Medicine Units Network found
previous vaginal delivery and epidural use
were associated with successful VBAC,
whereas previous cesarean for dystocia,
the need for induction, and maternal obesity lowered the success rate.9 Epidural
analgesia was significantly associated
with a successful vaginal birth (odds ratio,
0.37; 95% confidence interval, 0.33-0.41).
Because epidural analgesia does not mask
signs of uterine rupture, does not decrease
success rates of VBAC, and may improve
maternal acceptance of TOLAC, it seems
reasonable to offer epidural analgesia as
an option to women considering TOLAC.
The ASA Practice Guidelines for Obstetric Anesthesia state that Nonrandomized comparative studies suggest that
epidural analgesia may be used in a trial
of labor for previous cesarean delivery
patients without adversely affecting the
incidence of vaginal delivery. Randomized comparisons of epidural versus other
anesthetic techniques were not found.10
The recommendations in the ASA guideline are that Neuraxial techniques
should be offered to patients attempting
vaginal birth after previous cesarean delivery. For these patients, it is also appropriate to consider early placement of a
neuraxial catheter that can be used later
for labor analgesia, or for anesthesia in
the event of an operative delivery.

Anesthesiologists Awareness
of TOLAC Risk Stratification
In the obstetric literature, many publications on TOLAC and VBAC have focused
on predicting which women are most
likely to have a successful VBAC.

Impact of ACOG Guidelines on Anesthesiologists

Successful VBAC is associated with the
fewest complications, but failed TOLAC
has more complications than an elective
repeat cesarean delivery. When attempting to predict maternal morbidity, the
anesthesiologist and obstetrician must focus on the probability that she can achieve
a successful vaginal birth. Anesthesiologists may not be as aware of the risk
factors for failed TOLAC and uterine
rupture as their obstetric colleagues. The
anesthesia team must be kept informed of
her progress because they will be involved
if a laboring patient requires operative
delivery or resuscitation from a postpartum hemorrhage because of uterine rupture. Obstetricians and anesthesiologists
should communicate with each other
about individual patient characteristics
that predict her chance of VBAC success
or failure. If the obstetrician is concerned
about a failed trial of labor or symptoms of
a possible uterine rupture, the anesthesiologist must be aware. The anesthesiologist
should include patient characteristics associated with success or failure of VBAC in
their preanesthesia evaluation. Then they
can also assess which patients will be more
likely to require a repeat cesarean delivery
during labor.9,11
Factors that predict successful VBAC
include:
 Prior vaginal birth
 Younger maternal age
 Spontaneous labor
 Advanced cervical dilation on
presentation
 Lower body mass index at her first
prenatal visit
 White race/ethnicity
 Nonrecurrent indication for her prior
cesarean (eg, breech, fetal bradycardia).
Women who are more likely to require an anesthetic for repeat cesarean
are those with predictors of failed TOLAC
including:
 Prior cesarean for dystocia, cephalopelvic disproportion, or failed induction
 Augmented or induced labor

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Gestational age >40 weeks

No prior vaginal delivery
Increasing maternal age
Black or Hispanic race/ethnicity
Maternal obesity
Fetal macrosomia >4000 g estimated
weight.
Although there are no accurate predictors of uterine rupture, anesthesiologists
should be aware of the signs and symptoms of uterine rupture, and obstetricians
should notify the anesthesia team when
signs of possible rupture are present.
Signs of uterine rupture include abnormal
fetal heart rate, abdominal or shoulder
pain, vaginal bleeding, loss of fetal station, and intense uterine pain during and
between contractions that requires increasing number of epidural top-ups, or
is not relieved by epidural analgesia.68

The Preanesthesia Evaluation

of the Parturient Having
TOLAC
Uterine rupture is a real though unpredictable risk; resources must be available and
personnel prepared to manage complications. The anesthesia team should be notified when a woman having a TOLAC
arrives on L&D. An operating room
should remain prepared for emergency
cesarean delivery. If the obstetrics team
finds the patient has additional risk factors
such as airway abnormalities, previous
anesthetic complications (especially during
her prior cesarean delivery), thrombophilia requiring anticoagulant medications, chronic pain issues, etc., it is
preferable that the anesthesiologist meet
her during the antepartum period to assess
her risk and make a care plan for pain
management during delivery. As noted in
the VBAC guidelines, the availability of
good pain control using epidural analgesia
may encourage more women to choose
TOLAC. During the preanesthesia visit,
the anesthesiologist may be able to provide
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reassuring information about epidural analgesia and answer any questions about the
procedure that she or her partner may
have.12 This is best done before the onset
of active labor.
The airway exam is a particularly important part of the preanesthesia evaluation. A cesarean delivery during TOLAC
may be urgent or emergent without adequate time to place a spinal block or dose
an epidural catheter, especially if uterine
rupture has occurred. A review of airway
management in parturients provides an
algorithm for management of the unanticipated difficult intubation in obstetrics.13 It includes advice on how to
proceed with cesarean using mask ventilation or a supraglottic device (eg, laryngeal mask airway), and reminds us that the
ACLS guidelines for pregnant women
include performing a perimortem cesarean in the case of cardiac arrest. The use of
general anesthesia has other complications besides the potential for failed intubation during induction. A large study
of 303,834 women having cesarean delivery found the incidence of surgical site
infection within 30 days after surgery was
only 0.9%, but the odds ratio of infection
was 3.7 when general anesthesia was used
compared with neuraxial anesthesia.14
The authors speculate that neuraxial
anesthesia provides a sympathectomy
that increases blood flow and tissue
oxygenation at the surgical site. General
anesthesia also increases the risk for postpartum hemorrhage. A review of 67,328
women having a singleton birth by cesarean found those who received general
anesthesia had a higher rate of postpartum
hemorrhage than those receiving neuraxial
techniques; 5.1% versus 0.4%.15 After adjustment for other risk factors, the odds of
postpartum hemorrhage after cesarean delivery were 8.15 times higher in women
who had general anesthesia. The patient
will be counseled that neuraxial anesthesia
is preferable to general anesthesia when
possible.
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Intrapartum Care of the

Parturient Having TOLAC
The ASA Guidelines for Obstetric Anesthesia suggest reasonable intrapartum
oral intake.10 Clear liquids during labor
are acceptable in modest amounts. In
addition to water or ice chips, clear liquids
may include clear juices, popsicles, herbal
teas, clear sodas, or even black coffee.
Before the onset of active labor the patient
can even be given a clear liquid diet that
offers additional options if she strongly
desires oral intake and the anesthesia
team is comfortable with that plan. Solid
foods should not be offered during labor.
However, the ASA guidelines also state
that patients at increased risk of cesarean
delivery such as those with a nonreassuring fetal tracing or failure to progress,
patients with a potentially difficult airway
by exam, as well as those with risk factors
for aspiration such as obesity or significant diabetes should remain NPO. Aspiration has become such a rare complication
that some obstetric providers recommend
food in labor to improve maternal comfort
and birth outcomes. However, both the
ASA Closed Claims review of obstetric
anesthesia liability claims16 and the latest
review of maternal mortality in Great
Britain17 include cases of maternal death
because of aspiration, usually associated
with a difficult airway. Having clear liquid
options should be adequate for maternal
comfort, and there is no evidence that oral
intake during labor improves delivery outcomes. A prospective trial randomized
2400 women in labor to either a light diet
of solid foods or to only clear liquids to
determine whether oral intake of food
would lead to higher rates of vaginal delivery.18 They found no difference in the rate
of spontaneous vaginal delivery, instrumental delivery, cesarean delivery, rates of
vomiting, or duration of labor between
groups. Because aspiration is a rare event,
the study was not powered to address the
question of safety, but eating during labor

Impact of ACOG Guidelines on Anesthesiologists

did not lead to more vaginal deliveries.
Patients at higher risk of emergent cesarean
delivery and those with symptoms of gastroesophageal reflux should receive some
form of pharmacologic aspiration prophylaxis such as an H2-receptor antagonist,
metoclopramide, and/or clear antacid.
Should postpartum hemorrhage occur
after vaginal or cesarean delivery, the anesthesia team should be immediately involved to assist with the resuscitation and
to help ensure patient safety and comfort.
In accordance with the World Health
Organizations guidelines for management
of postpartum hemorrhage published in
2009, all hospitals that provide obstetric
services should have approved a formal
protocol for management of maternal
hemorrhage to ensure there is no delay in
treatment.19 The World Health Organization guidelines provide an evidence-based
algorithm that starts with (1) uterine massage and oxytocin, (2) ergot medications
such as Methergine, and (3) prostaglandins
such as Hemabate and Cytotec. If these
steps are unsuccessful, they recommend
additional maneuvers including (1) bimanual uterine compression if there is uterine
atony, (2) intrauterine balloon tamponade
(eg, Bakri postpartum balloon), (3) uterine
artery embolization if there are resources
for interventional radiology techniques,
(4) compression sutures (eg, B-Lynch procedure), (5) hypogastric, uterine, or other
vessel ligation, and (6) hysterectomy. Isotonic crystalloids rather than colloids are
recommended for fluid resuscitation. The
anesthesia team must be aware of the
algorithm so they know what to have
available and what techniques might be
attempted next, and they must be cognizant of the side effects and complications
of each medication and procedure.
If a catastrophic uterine rupture has
occurred, and hysterectomy or a lengthy
uterine repair is necessary, the anesthesiologist will place additional large-bore
intravenous access and an arterial line
for frequent blood draws to follow

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hemoglobin, platelet count, fibrinogen

and INR, and base deficit for adequacy
of resuscitation. The hospital blood bank
should already have a type and screen or
type and cross available for the patient,
but they should now prepare packed red
blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio. Measures must be
taken to warm the patient and maintain
normothermia. Warming devices (eg,
Bair Hugger Warmer) should be placed
on the patient if not already in use, and the
temperature in the room should be increased to prevent hypothermia that
could affect her coagulation status and
increase the risk of later infectious complications. Only warm intravenous fluids
should be used, and all blood products
transfused will go through fluid warmers
such as the Level 1 (R). Additional antibiotics may be needed if blood loss is
extensive. Even if the patient has a wellfunctioning neuraxial anesthetic, there
may be a need to provide sedation or
induce general anesthesia to ensure patient comfort and to protect her airway
during hemodynamic instability.

Immediate Postpartum Care of

the Parturient
After general anesthesia or large volume
resuscitation, the team must decide where
to recover the patient. A survey of 135
obstetric anesthesia directors in North
American academic institutions asked
them for information about their postcesarean recovery rooms on L&D, and
reported some disturbing results.20 Fortyfive percent of institutions do not require
their L&D nurses to have any training
specific to postanesthesia nursing care. In
79% of institutions the nurse has other
responsibilities besides the patient recovering from general anesthesia such as
normal newborn care, breastfeeding support, or care for additional patients. In
63% of institutions the nurse must leave
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Hawkins

her recovering patient to obtain medications, monitoring equipment, or even to

chart. In only 85% of hospitals was an
Ambu bag in the same room as the patient. When asked to compare the quality
of care in their L&D recovery room to
that provided to general surgical patients
in the main operating room, 43% reported lower quality. Because neuraxial
techniques are the primary anesthetic for
cesarean deliveries, nurses on L&D have
very little experience with general anesthesia and the complications that can
occur in the recovery period. Be aware
of the nursing resources in your facility
when recovering a high-risk parturient
after a complicated anesthetic or surgical
procedure. The main operating room recovery area or an intensive care unit bed
may be more appropriate if the patient is
not completely stable.

Conclusions
Anesthesiologists should be involved in
the counseling and care of patients having
a trial of labor after previous cesarean
delivery. Reassuring the patient that she
has options for good pain relief during
labor may encourage her to attempt
VBAC. The anesthesia team should be
notified when a patient on L&D is having
a TOLAC delivery so they can perform a
preanesthesia evaluation early in her labor. If there are medical factors that
might complicate her course, the anesthesiologist should be consulted before
labor in the antepartum period. An anesthesia consult can often be coordinated to
coincide with an obstetric prenatal care
visit or a prenatal tour of L&D. Appropriate NPO status should be maintained
while the patient is in labor. Early placement of a neuraxial anesthetic may avoid
the need for general anesthesia if an urgent cesarean delivery becomes necessary.
During labor, if the obstetrician is concerned that the patient will not have a
successful VBAC or that there is an
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impending uterine rupture, they should

clearly communicate their concern to the
anesthesiologist so that both teams are
prepared to perform cesarean delivery
without delay if it becomes necessary.

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