9722123, 12:01 PM \Vaginal Birth iter Cesarean Delivery -StatPearls - NCBI Bookshelf ‘Vaginal Birth After Cesarean Delivery Haak PJ, Kole M, Continuing Education Activity ‘egina birth ater cesarean section (VBAC) desribes a vagival delivery in 2 women who has given bith via cesarean section in a former rognaney Patients dessing VBAC delivery undergo a wal of labor (TOL), ako elle wil of labor ater cesarean section (TOLAC)- While TOL isan accepted and generally safe practice, serious potential complications include werine ropuor uterine dehiscence and assoiated maternal andlor neonatal morbidity. Providers caring for patients with prior cesarean section nce to counsel patients regarding potent risks and benefits oF TOL andthe factors which affect the likelihood of successful vaginal delivery. These providers must be knowledgeable regarding inapartum management of patents undergoing TOLAC and able to recognize and appropriately manage potential complications. This activity reviews the ‘valuation and management of patents undergoing vaginal bn afer cesnrea delivery and highligh the ole of interrofessional tara ‘members in collaborating to provide wll-soordinated cae and enhance outcomes for affestod pation Objectives: + List the potential risks of vaginal bit afer cesarean seston, + List the potential benefits of vaginal bin fer cesarean ston. bit afer cesarean section. ‘+ Describe the factors that intacnce the outcomes of vag + Explain the importance of improving care cordon, with particular emphasis on communication between interprotesiona medica teams, to enhance outcomes for patients undergoing vaginal bith after cesarean section. Acca ree multiple choice questions on this tpi, Introduction ‘egina birth after cesarean section (VBAC) isthe term aplid to women wino undergo vaginal delivery following cesarean detivery ina prior pregnancy Patients desiring VBAC delivery undergo a wal of labor (TOL) oral of labor after cesarean section (FOLAC). While TOL isan acceptable, generally safe practice, serious, potential complications include uterine rupture or dehisenee with associated maternal andlor neonatal morbidity Providers caring for patents with prior cesarean section ned to be aware of and abl to counsel patients regarding risks and benelits of atempting TOL, factors which affect the lkelibood of succesful vaginal delivery, and knowledgeable egarding intrapartum, ‘management of patents undergoing TOLAC. Etiology {As the cesarean delivery rate has increased so asthe numberof patients becoming pregnant who have experienced cetarean section in a prior pregnancy Patients may undergo vaginal bith after cesarean section either a planned procedre or dae to precipitant ako Epidemiology Since 1970, the rate ofcosarcan delivery es inceated dramatically Som 5% in 1970 to 30% in 205 [1/The rate of cesarean delivery peaked in 2009 at 32.9% and was 31,9% in 2016.2] In the ealy 1970s, when the cesarean delivery rate fist began ort, it was generally felt by medical providers that if patient hd had cesarean section, she should deliver ll ture babies by this route, eallicare professionals began to question the dictum, “once a cesrean, alvays a cesar ad subsequently, he numbe of patients undergoing VBAC delivery began to inteae, From the mit 80s tothe mid-19905, TOLAC was encouraged, and an increase in VBAC delivery was seen along witha concomitant ecrease in cesarean delivery Between 1985 and 1995, the VBAC rate increased by ver 20% with an associated decrease in eotrean section rates. As VBAC became mare common over his time odd the amber of reported significant complications. Such complications and accompanying malpractice suits et to a decrease in VBAC. Complications in patents undergoing TOLAC can occur, however, appropritely selected patients an benefit from attempting a vaginal delivery | the appropiate seting, When sucessful, VBAC is asociated witha doerease in matemal morbidity and decreased risk of complications in future pregnancies. Patients who have undergone succesful VBAC benefit fam the avoidance of supeal recovery in the postpartum pio. Increase in VBAC deliveries als wil serve to decrease the overall eesarean dliveryrte, More rece it recognized tha asthe number of cesarean sttins a patient underges increases so docs he risk of significant obstetrical complications. These complication include massive postpartum hemocage,placents previ, and related placetal disorders. [3 )By avoiding multiple cesarean deliveries, patients planning large families may particulary stand to benef from undergoing vaginal birth after cesarean section hitps:twwnncb.nim.nih.gov?booksINBKS07844/?report=reader 189722123, 12:01 PM \Vaginal Birth iter Cesarean Delivery -StatPearls - NCBI Bookshelf History and Physical All pregnant patients should haves comprehensive history and physical exam atthe intl prenatal visit a well son admission to labor and avery. History should include a detailed bstetic history consisting of the yea of any pio pregnancies, and pregnancy outcome (abortion, topic, or dlivery). Weight and gestational age ofthe infant at delivery shouldbe recorded, I patients have had complications with prior repnances, tis should be noted and pertinent det is desribe, Ia some cats, it wll be beneficial to obtain ecords from prior prenatal care providers or from the hospital a which the patient delivered her other bie Concerning mode of delivery, itis important to note if rior babes were delivered vaginally or by cesarean section, For patients experiencing prior ope noted, Healy the operative nots of any prior delivery should be obained and a copy a 1 deivery (ether operative vaginal delivery or cesarean section) deals abut the indications far operative delivery should be nthe patient’ chart, (General physical exam ina patient with a prior cesarean section is performed. The pelvic exam may include an assessment of eincal pelvimetry hich isa series of assessments designed to predit the likeli ascestment has not hen found tobe highly predicted of succesful VBAC or vagina delivery and should not be used a a sole predictor to od of vaginal delivery. While clinical pelvimety is frequen performed, this Aetermine if patent ean undergo a tril of labor For patens planning trial f labor after cesarean section, a pelvic exam close to term may’ provide adional guidance regarding delivery planing. Ripening ofthe cervix (softening and elficerent and low station ofthe fea head provide some encouragement that patent may be ‘mote likely to ene aborspontancously. A nea attempt should be made to estimate he fetal weght cir by physica exam or using uluasonographic assessment, This information shouldbe considered but should not be used singulanyto deters if ial of labor should be stempled, a n0 method for determination of fetal birth weight are highly accurate, Evaluation Some women will not be candidates fr TOLAC. Patients having had pir classical cesarean section or prio incision into the contractile prton ofthe uterus have higher rates of urine rypure, and thus, a planed, repeat cesarean section isthe recommended mode of delivery. Iealy, ‘operative reports rom prior surgeries should be absined and reviewed fora description of the previous werne incision. When this i no Because the posible, for example when prior surgery ws performed in another country, the patient considered to havea “unknown ca ‘vast majority ofcesarcan sections are performed with alow, transverse, uerineinssion, it is reasonable to query the patient about the circumstances surounding her delivery. Ifthe history does not suggest a sccnai in which vertical incision would have been likely, for example, ‘cesarean setion performed at 24 weeks when the lower uterine sepmeat is less key to be developed it i easonale tallow TOL. The ate of terne rupture i this situation has been fourd o be similar tothe ate for patients wih rior low transverse cesarean section (4) Likewise the ate of uterine ruptures fel fo increase with increasing number of prior cesarean sections, With 1 prior LUIS the rate of werine rupture is les than 1%; whereas, the rates slightly higher with 2 prior cesarean sections at 0 2%, Most practitioners consider patients with up to swo prior cosaran deliveries tobe candiates for TOLAC, this recommendation is also endorsed bythe American College of Obstetrics and Gynecology 4] Patents with ater conditions involving incision into the upper or contractile portion ofthe uterus ate generally fel ot tobe candidates for TTOLAC asthe rate of uterine rupture is unacceptably high in these stations. In ation to prior classical terine incision such conditions would Include prioe "To" ype incision at cesarean delivery or prior tansmyometrial incisions o resect urine fibroid oto ficlitate open fetal surgery. Patons with a prio history ofucrinerupu also havea high rate of uterine rupture and planed repeat cesarean delivery is recommended prior othe onset of labora approximately 36 to 38 6/7 weeks estimated gestational age. (4) Facilities offering FOLAC should have the capability 1 perform an emergency eosrean delivery. While the availabilty of such esouees seems prudent concen has hee raise tha this equiement iis some patents, such those living n rural areas, fom having the option of vaginal daivery ater cesaret tection nthe mos recent ACOG Practice Bulletin on this ope, it was recommended to consider referral af uch patents to sites able to offer TOLAC when appropriate. It was also noted tat with cere counssling some patents might choose TOLAC even in situations whore resources are imited(4] In considering TOLAC versus PRCD patients may also benefit ram counseling regarding likihood of vaginal delivery. The rte of suscessal ‘vaginal delivery after a rior cesarean sections found tobe 60% to 80%) Tn general, patients with non-tcuring indications for esarean section, for example, breech presentation, ate thought to have higher ikibood of vaginal delivery. Patients with prior vaginal delivery also are found to have higher sucess ates of vaginal delivery, VBAC calculators are also available to developed fom Metermal-Fetal Medicine Units Network 5 litte estimation of success such asthe one Pats entering lnbor spontancously have higher success ates as well, when compared to women undergoing induction of abr. hitps:twwnncb.nim.nih.gov?booksINBKS07844/?report=reader 2159722123, 12:01 PM \Vaginal Birth iter Cesarean Delivery -StatPearls - NCBI Bookshelf Treatment / Management Patents planing a al of labor after cesarean section require sypial prenatal care with additonal counseling regarding the option of TOLAC versus PRCD. Aditionally,catyulrasound to confirm gestational age canbe help ia cesarean section is schedule. With regards to labor management, spontaneous entry int labors prefered as spontancous labor carries a higher rik of successful vaginal dative and a lower risk of urine rotue6]Indution of labor remains an option when indicated however use of prostaglandins for cervical ‘pening a several sie have demonstrated increased risks of uterine rute when prostaglandins (uch as misoprostol or dinoprostone) are se fr cervical pening, In some centers use of low-dose oxytocin andor mechanical dilation with tracervical balloons is sed to alte Induction in patents undergoing TOLAC wih an unripe cervix. Studies of use of mechanical ltrs wen used in the seting of VBAC are limited and show mined results.) ‘Wile not equized epidural analgesia may be usefl in improving patient comfort withthe benefit of providing a rapid option for anesthesia essarean deliver is requived Patents should have fetal heart tones monitored closely in labor an attention shouldbe made 1 appropriate labor progress. Continuous fetal heat rate monitoring i stongy commended, IFconcers arse about posible uterine dehiscence or rupture eesaean delivery should be performed pomply. The mos! common sig af werine rupture it an abnormaliy ofthe fetal hear rte tracing, which is seen i approximately 70% of cases of uterine pure (4}Other findings which may be sen if trie rupture ocurs include increase or decrease in werine contractions, severe abdominal pin/ain out of proportion fr lor, aden loss of fetal sation or finding of blood inthe urine o rine collection ba, ven with close and meticulous monitoring eine rupture can occur suddenly and without warning resulting in Fetal compromite, fll damage o death ‘Voginal delivery, delivery ofthe placenta and postpartum supports typical for patients undergoing VBAC delivery, Rarely, manual exploration ofthe utes following placental delivery may led to suepicion or discovery of previously undetected dehiscence ofthe wine tea Repair of| such defects not riod unless thee is ongoing bleeding Likewise, patints may experience oovul uterine rupture whic can lado bleeding following delivery. VBAC patients experiencing post delivery hypotension or ater signs of hypovolemia shouldbe evaluated promptly with consideration given tothe possible dignosis of uterine raptare Differential Diagnosis + Amnionitis + Pace and Brow Pressman + Fae labour + Mapceentaton + Obstction + Pregnancy, Delivery + Uierine anomaly Complications ‘The mos significant complieaton which ean eer patents undergoing TOLAC is wesne rape which involves the incision made into the tera atthe time ofthe prio ssarean delivery. Uterine rupture sa medcl emergency and patients must be taken immediately fr lparotomy for delivery ofthe fetus and to address and additional complications When uterine rupture occur, transfer of blood and oxygen to the baby is interrupted, an his can result in fal complications inching fetal acidosis, «need fr neonatal intensive care nit (NICU) admission, and even death While the absolut sk of perinatal matty is low with TOLAC, thers slightly higher when compared to babies born to mothers undergoing panned repeat cesrean delivery (13 versus 0.05%). In cases of uterine rupre risk othe mother is aso significa, Patents may experience significant hemorchage. When hemorthage occur inthis setting transfusion, and sometimes hysterectomy, is necessary to control ceding and can be life-saving Uterine dehiscence is also desribed. Dehiscence dif fom a uterine rptare in that he outer serosal layer of the ters may remain intact hile she underlying muscular layers have opened allowing for visualization ofthe amniotic sac and fetus. Alternatively, all layers ofthe uterus may have separated however the fetus remains safe within the uterus thru this small opening. Such finding soften refered to as “uterine Window" Patients with werne dehiscence are mos often asymptomatic, and the more serious sequela tat can aecur with eine repre are not «encountered. When reviewing scholarly artes about uerine scar rupture and dehiscece the distinction between the two isnot alvays clear Sometimes making study conclusions dificult wo iterpret hitps:twwnncb.nim.nih.gov?booksINBKS07844/?report=reader 359722123, 12:01 PM \Vaginal Birth iter Cesarean Delivery -StatPearls - NCBI Bookshelf Some patients attempting TOLAC may require cesarean delivery. When this occurs afte Tabor, the risks of postpartum infection, werne stony, and wound separation are higher in comparison to patients who have planed repeat cesarean section. Enhancing Healthcare Team Outcomes ‘Tae management of patents undergoing vaginal delivery afer prio cesarean sections best done with an iterproessional team that includes labor and delivery nurses. An abtetrician should always be present nd an operating rom with anesthesia stand by most be ready incase & cesarean section ie needed, While succesful vaginal deliveries have occured following prior cesarean sections, there are ample report of terine rpure- hence clnial acumen in desi mal ismocessary to avoid Itigaton Review Questions 1+ Accs fee mile choice questions on this topic + Comment on this article References 1 Scott JR. Vaginal beth ater cesarean delivery a common-sense approach. Obstet Gynccol. 201] Aug; 118(2 Ps 1):342-380. (PubMed: 20778881] 2. Martin JA, Hamilton BE, Osterman MIK. Bis in the United Sates, 2016. NCHS Data Brie: 2017 Sepx287}:1-, [PubMet 29155584) 3. Marsall NE, Fu R, Guite JM. Impect of multiple cesarean deliveries on matemal morbidity systematic review. Am J Obstet Gynec 2011 Sep:208(3):262e1-8. [PubMed 22071087] 4. ACOG Practice Bulletin No, 208: Vaginal Bith Aer Cesarean Delivery. Obstet Gynecol 2019 Feb;138(2)e110-e127 [PubMed: 30681883] 5. Grobman WA, La ¥, Lendon MB, Spon CY, Leveno KJ, Rosse DJ, Vorer MW, Moawad AH, Canis SN, Harper M, Wapaer RI, Sorokin ¥, Miodovnik M, Carpenter M, OSullivan My, Sibsi BM, Langer 0, Thorp JM, Ramin SM, Mercer BM. National Insite of Child Halt, sd Human Development (NICHD) Matemal-Fetal Medicine Units Network (MFMU). Development of nomogrum for prediction of ‘vaginal bih fer cesarean delivery, Obstet Gynecol, 2007 Apr 09() 806-12, [PubMed 17400840] 6. Guise IM, Eden , Emeis C, Denman MA, Marshall N,Fo RR Janik R, Nyeren P Walker M, McDonagh M. Vaginal birth afer cesarean ‘ew insights. Evid Rep Technol Assess (Full Rep. 2010 Mar,(191):1397, [PMC fice anicle: PMC4781304] PubMed: 20629481] 7. Guise IM, Denman MA, mes C, Marshall N, Walker M, FuR, Janik R, Nygren P, Eden KB, McDonagh M. Vegizal ith ater eosrean now isights on maternal and neonatal outcomes, Obstet Gynecol 2010 Jun] (6) 1267-1278, [PubMed: 20502300] Disclosure: Paticia Haba declares no relevant nancial relationships with ineligible companies, Disc fara Kole declares no relevant financial telationships with nsigible companies. Publication Details Author Information and Affiliations dhs Pavia. bat; Mars Kale iiaions 2 Mseopa Mecca Cntr * Worman and ars Hosa Publication History ast peat Ju 37,223. Copyright Cope © 202, Sata Pubisting Lic. “his books strut unearth toms fh Creative Commons Aiton NerConmari NoDarates 40 rsationa (20 BYNC-NO AO} lsat vane eriansesty-e-8) wich arms charsta dbus tha wrk, provide ta he aril i ot kr or ted omar Your at ‘equa oan permission dsb is art, proved tht you rh stor ar jour, hitps:twwnncb.nim.nih.gov?booksINBKS07844/?report=reader 459722123, 12:01 PM \Vaginal Birth iter Cesarean Delivery -StatPearls - NCBI Bookshelf Publisher ‘SaPeat Publi, Treasure nd FL NLM Citation ata P, Kale Vagina sir tar Cesarean Oley Updated 2028 27h: Stow rte, Tease and (FL: SltPeats Publishing: 2023 Jr hitps:wwnsncbi.nim.nin.govfbooksINBKSO7844/?reportsreader 55