VBAC and the Role of the

Anaesthetist
 Disclosures
Off-label use of drugs may be discussed
Objectives
Upon completion of this lecture, participants will be able to

•Know the epidemiology of repeat cesarean delivery and

trial of labor with vaginal birth after cesarean
•Understand the maternal benefits and risks of repeat
cesarean delivery vs. trial of labor after cesarean
•Understand the neonatal benefits and risks of repeat
cesarean delivery vs. trial of labor after cesarean
•Know current guidelines and recommendations regarding
repeat cesarean and trial of labor after cesarean
Outline

• Epidemiology VBAC / TOLAC

• Maternal risks and benefits
• Neonatal risks and benefits
• Current guidelines
Zhang J. Am J Obstet Gynecol 2010; 203: 326.e1-10

Overall Cesarean Delivery Rate 33%

Repeat CD

19% Primary, spontaneous

31% labor, nullip
Primary, spontaneous
labor, multip
13% Primary, induction of
labor
8% 8% Term prelabor CD
2%
19% All preterm CD

All multiple gestation,

Silver RM. Obstet Gynecol 2006;107:1226

Placenta Accreta
Silver RM. Obstet Gynecol 2006;107:1226
Placenta Previa: Risk for Accreta

Uterine Scars Risk of Accreta

0 3%
1 11%
2 40%
3 61%
4 67%
 Grobman WA. Obstet Gynecol 2007;6:1249

Multiple Cesarean Deliveries

Composite maternal variables: transfusion, hysterectomy, operating

injury, coagulopathy, VTE, pulmonary embolism, death
Definitions

• TOLAC: Trial of Labor After Cesarean

• VBAC: Vaginal Birth After Cesarean
• ERCD: Elective repeat cesarean delivery
• Failed/unsuccessful TOLAC
ACOG.SMFM Obstetric Care Consensus
Am J Obstet Gynecol 2014;123:963-711

Overall CD

1°CD
Cesarean Delivery
and VBAC Rates
VBAC
Vs.
Trial of Labor after Cesarean (TOLAC)
Problems with current data
• Most studies compare by actual mode of delivery, not
intended mode of delivery
• Differentiate indicated from ERCD
• Data are for short-term outcomes
• US vs. non-US data
• Gestational age
• Retrospective vs. prospective
• All observational
• Tertiary care settings
AHRQ Publication No. 10-E003

TOLAC – Vaginal Delivery Rate 0.74 (0.72, 0.76)

MacDorman M. Clin Perinatol 2011;38:179-92
Maternal Outcomes
• Short-term
– Death
– Uterine rupture
– Hysterectomy
– Transfusion/hemorrhage
– Infection
– Surgical injury
– LOS
• Long-term: multiple cesarean deliveries
AHRQ Publication No. 10-E003

Maternal Death
16

14

12 13.4
Deaths per 100,000

10

2 3.8
0

TOLAC ERCD
95% CI: 0.9-15.5 4.3-41.6
Guise JM. Obstet Gynecol 2010;115:1267

Systematic Review: Maternal Summary

AHRQ Publication No. 10-E003

Risk of Uterine Rupture with TOLAC

0.46% (95% CI 0.31-0.69)
AHRQ Publication No. 10-E003

Risk of Uterine Rupture:

TOLAC vs. ERCD

• RR: 20.7, 95% CI 9.8 – 44.0

• Per 1000, additional 5.1 ruptures
(95% CI 2.3 – 11.2)
Anna
Neonatal Outcomes
• Short-term
– Perinatal death
– Sepsis
– Apgar scores
– NICU admission
– Breastfeeding
• Long-term
– Neurologic development
– Future pregnancies
AHRQ Publication No. 10-E003

Perinatal Death RR: 1.82 (95% CI 1.24-2.67)

Risk difference: 0.41% (0.012-0.08)
140

120 133
Deaths per 100,000

100

80

60

40 50
20 TOLAC ERCD
0
Guise JM. Obstet Gynecol 2010;115:1267
Systematic Review: Neonatal Summary
AHRQ Publication No. 10-E003

Maternal and Perinatal Death

140
120 133
Deaths per 100,000

100
80
60
40 50
20
3.8 13.4
0
Maternal Perinatal
Predicting Risk of Uterine Rupture?
N = 11,855

AUC 0.627

Grobman WA. Am J Obstet Gynecol 2008;199:30.e1-5

Am J Obstet Gynecol 2009;201:320.e1-6

FT < 2.3 mm
AUC 0.88 (95% CI 0.79-0.98)
PloS One 2017;12:e0187850

• Danish birth registry 1997-2008 (N = 39,742)

• TOLAC: with (n = 175) / without (n = 272) uterine rupture
• Primary outcome: complete uterine rupture
PloSOne 12:e0187850

Risk factors for uterine rupture: Pre-labor

Wen SW. Am J Obstet Gynecol 2004;191:1263

TOLAC: Successful vs. Unsuccessful

McMahon MJ. N Eng J Med 1996;335:689

TOLAC: Successful vs. Unsuccessful

Morbidity and Mortality

Unsuccessful TOLAC >

ERCD >
Successful TOLAC

Can we predict successful TOLAC?

ACOG Practice Bulletin No. 115. Aug 2010
BJOG 2014;121:183-93

• UK: Hospital episode database, 2004-2012

• N = 143,970
BJOG 2014;121:183-93

• Risk factors for failed TOLAC

– Older ager
– Nonwhite
– Long birth interval (> 3 y)
– Prior emergency CD
– Indication for prior CD
– Maternal co-morbidities: DM, HTN
– Higher birth weight
 VBAC Prediction Model

http://www.bsc.gwu.edu/mfmu/vagbirth.html

Grobman WA. Am J
Perinatol 2009;26:693
Grobman WA. Am J Perinatol 2009;26:693

ROC Curve for VBAC Model

ROC: 0.78 (95% CI 0.77 – 0.79)

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_45.pdf
RCOG. Green-top Guideline 45: 2015
Signs and Symptoms of Uterine Rupture
• Fetal bradycardia (70%)
• Increase/change uterine contractions
• Loss of fetal station/change in abdomen
• Vaginal bleeding
• Hypotension
• New onset pain/pain between contractions
– Referred shoulder pain
• Single-center, retrospective, 2006 – 2013
• TOLACs (n = 7149)
• Epidural (n = 4081; 57.1%) vs. non-epidural
• Primary outcome: mode of delivery
J Perinat Med 2018; 46:261

Epidural Non-epidural P-value

N = 4081 N = 3068
Cesarean 8.7% 11.8% < 0.0001
Instrumental VD 11.7% 2.8% < 0.0001

aOR 4.58 (95% CI 3.67 to 5.70

TOLAC Conclusions

• TOLAC success rate 74%

• Maternal mortality: ERCD > TOLAC
• Perinatal mortality: TOLAC > ERCD
• Worst outcomes for unsuccessful TOLAC
• Neuraxial labor analgesia for TOLAC
– Breakthrough pain