Vaginal Birth After C-Section (VBAC): The old phrase "once a C-section always" is no longer true.

In the past, the belief was that if a woman had delivered one baby by C-section, all other children had to be delivered the same way. Today many women can have vaginal deliveries after a previous C-section delivery. This is referred to as a vaginal birth after cesarean (VBAC). Candidates For VBAC: According to the American College of Obstetricians and Gynecologists (ACOG), the following women are candidates for VBAC:

The woman has had one prior low-transverse C-section delivery. This refers to the cut on your uterus, not the one on your belly. If youve had a prior c-section, your health care provider may ask you to get a copy of the report from your first surgery to check what type of incision you had on the uterus.

The woman has had no other uterine scars or ruptures, whether from previous Csections or other surgeries. The woman has a pelvis large enough to allow a vaginal delivery. Delivery will be at an institution with a physician immediately available throughout active labor who can monitor the fetus and perform an emergent C-section if needed. Delivery at an institution where anesthesia and staff is also immediately available if an emergent C-section needs to be performed.

ACOG has specifically stated that whenever a woman is planning a VBAC delivery, there should be an appropriate medical team available, including an anesthesiologist, throughout the active labor so that an emergency C-section may be done if necessary. Smaller hospitals may not have the resources to monitor a VBAC delivery or to provide an emergency c-section for VBAC situations, and VBAC delivery may not be possible. Women Who Should NOT Have VBAC: One of the main concerns with having a vaginal delivery after a C-section is the potential rupture of the uterus, which could be harmful to you and the baby. Therefore, ACOG has made recommendations for women who should not try a VBAC delivery. These women include:

Women with a high vertical (or classical, T-shaped) incision on the uterus Women with a history of extensive uterine surgery Women with a small pelvis or delivering a large baby - it may not be safe for the baby to pass through the pelvis Those with a medical problem or obstetric condition, such as placenta previa or abrubtio placenta Women delivering in a hospital without an available medical team for VBAC monitoring and emergency C-section Prior uterine rupture Women with two prior C-sections and no previous vaginal deliveries

The Benefits of VBAC: Statistically, about 60-80% of women who try VBAC are able to deliver vaginally. If you are considered a candidate for VBAC, there are some advantages to having a vaginal delivery over a C-section. Some of these include:

Shorter hospitalization No abdominal surgery Lower risk for blood transfusion and infection Overall faster recovery May avoid multiple future c-sections if you are considering a large family (with three or more children)

Notably, however, some women who try to have a vaginal delivery end up with a c-section. They dont get to experience these benefits. Risks: The most serious risk with VBAC is rupture of the uterus. The risk of rupture of the uterus after a prior low transverse c-section is about 1 percent, whereas the risk of rupture of the uterus in previous classical C-section is 8 to 10 percent. In a recent large study, about 1 in 2,000 women who tried to VBAC had a uterine rupture that caused permanent brain damage for the baby. Women in the group that tried to have a vaginal delivery were also more likely to need a blood transfusion and more likely to have an infection in their uterus that required antibiotics. On the other hand, about three quarters of the women who tried to have a vaginal delivery succeeded. These women avoided surgery and had a quicker recovery compared with the women who chose to have a scheduled repeat c-section. The Final Decision Is Yours: The key to making a decision about VBAC is to discuss with your health care provider the risks and benefits for both you and your baby. The circumstances are different for everyone, and it is important to seek guidance from your health care provider to discuss your risks. Ultimately, the decision is yours. The more information and understanding you have about VBAC, the easier it will be to make a decision.

Medscape ntroduction
"Once a cesarean, always a cesarean." From the time they were spoken in 1916 to the New York Association of Obstetricians & Gynecologists over the ensuing 50-60 years, these words reflected most of US obstetricians' management of patients with a priorcesarean delivery. By 1988, the overall cesarean delivery rate was 25%, rising from less than 5% in the early 1970s. Only 3% of live-born infants were delivered vaginally after the mother had undergone a prior cesarean delivery. Although attempts at a trial of labor after a cesarean birth have become accepted practice, the rate of successful vaginal birth after cesarean delivery (VBAC), as well as the rate of attempted VBACs, has decreased during the past 10 years. Whereas, 40-50% of women attempted VBAC in 1996, as few as 20% of patients with a prior cesarean delivery attempted a trial of labor in 2002. This number is drifting down toward the 10% mark with fewer than 10% of women achieving successful VBAC in 2005. Several factors have contributed to this decline. As practitioners experience complications related to managing patients undergoing trials of labor after cesarean delivery, they are less likely to allow new patients to undergo a trial of labor. In addition, 1999 guidelines from the American

College of Obstetricians and Gynecologists (ACOG) clearly state that patients undergoing a trial of labor after cesarean delivery require the presence of an obstetrician, an anesthesiologist, and/or a staff capable of performing an emergency cesarean delivery throughout the patient's active phase of labor.1 While academic centers and larger community hospitals readily comply with this requirement, many smaller hospitals do not offer in-house anesthesia or obstetric staff. Furthermore, to meet the financial demands of managed care, many obstetricians now cover more than one hospital simultaneously, making it difficult to meet the ACOG guidelines. The impact of these changes can be observed in national birth statistics. The cesarean delivery rate peaked at 25% in 1988, but then declined to 21% overall in 1996. However, from 1996-2004, the cesarean delivery rate increased to 29.2%, while the rate of VBAC declined from 28% to 9%. Assuming an overall 70% VBAC success rate, this correlates with a decline of 40% to 14% in the number of patients with a prior cesarean birth choosing to undergo a trial of labor. What once was hailed as a key component of lowering the overall cesarean birth rate (ie, trial of labor in patients with previous cesarean birth) is losing the support it had in the 1980s. Overall, this has led to a rate of cesarean delivery of 31.1% in 2006, the highest rate in US history, with no signs of decreasing. When considering which patients should be offered a trial of labor after cesarean delivery, compliance with ACOG recommendations must be ensured. Once compliance is established, patients should be routinely counseled early in the pregnancy regarding the risks and benefits of a trial of labor. Many obstetric practices and healthcare institutions have adopted a separate consent form for patients wishing to attempt a VBAC. While consent helps to formalize counseling, documentation of the overall risks quoted to the patient, specifically mentioning the individual's risk factors, is all that is truly necessary. However, because of medical-legal concerns, formalized written consent forms, and even video-taped counseling-consent interactions, are used by clinicians around the United States. Two specific outcomes of interest regarding a trial of labor after cesarean delivery have been well investigated: successful VBAC and uterine rupture. Other outcomes are certainly of interest, including neonatal outcome, hysterectomy, and maternal mortality; however, few studies have focused on these outcomes, and poor outcomes occur too rarely to be well represented in established databases. In earlier studies, most outcomes were reported after univariate analysis. Risk factors were examined without controlling for potential confounding variables, and results were reported as a relative risk or odds ratio. These ratios represent the risk of the group of individuals who have the risk factor divided by individuals without the risk factor. Over the last decade, several large cohorts have examined predictors and outcomes related to women with a prior cesarean delivery. These studies have ranged from Nova Scotia to Boston to the state of Washington. Finally, 2 large multicenter studies have been publishing multiple studies on this issue, one out of Pennsylvania and the other out of the Maternal-Fetal Medicine Units. These large studies over the last decade have used multivariate statistics to examine risk factors. This means that other risk factors and confounding factors, such as birthweight, maternal age, obstetric history, and labor management, were controlled for in the analysis. In this article, factors associated with mode of delivery in the setting of a trial of labor and factors associated with uterine rupture in this same setting are reviewed.

For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Labor Signs.

Predictors of a Successful Trial of Labor

The predictors of a successful trial of labor after cesarean delivery are extensively described in the existing literature (see Table 1). While no randomized trials have been conducted, relatively large databases have been analyzed (using both univariate and multivariate techniques) to determine risk factors for patients undergoing a trial of labor after cesarean delivery. In addition, several scoring systems have been devised to help predict which patients are likely to be successful when attempting a vaginal birth after cesarean delivery (VBAC). Because no large, prospective, randomized, controlled trials have been conducted, most of the risk factors have been determined from retrospective cohort and case-control studies. These studies have been increasingly analyzed with multivariate techniques, allowing for control of confounding factors. However, control for physician practice is difficult, and physician practice can greatly impact the strength of the association between these risk factors and a successful VBAC. Even when controlling for demographic data, obstetric history, birthweight, gestational age, induction of labor, and other variables, the bias inherent in nonrandomized and nonblinded trials cannot be eliminated.

Table 1: Predictors of VBAC Success or Failure Open table in new window Increased Chance of Success Prior vaginal delivery Prior VBAC Spontaneous labor Favorable cervix Nonrecurring indication (breech, previa, herpes) Preterm delivery Decreased Chance of Success Maternal obesity Short maternal stature Macrosomia Increased maternal age (>40) Induction of labor

Recurring indication (cephalopelvic disproportion [CPD], failed second stage) Increased interpregnancy weight gain

Latina or African-American race/ethnicity Gestational age 41 weeks Preconceptional or gestational diabetes mellitus Maternal characteristics Several studies examine prepregnancy weight and height to examine the effect on mode of delivery. Not surprising, women who are shorter and women who are obese are more likely to undergo cesarean delivery. Of note, not only increased prepregnancy weight, but increased gestational weight gain has been associated with cesarean delivery. In the setting of trial of labor after cesarean delivery, an increasing number of studies exist, all of which show that women in the morbidly obese range have a higher risk of failing a trial of labor. Interpregnancy weight gain has been shown to increase the risk of failure in a subsequent trial of labor, but unfortunately, interpregnancy weight loss has not demonstrated an improvement in VBAC success. Maternal age has also been examined in several studies in VBAC literature. Adjusting for confounding factors, women older than 40 years who have had a prior cesarean delivery have an almost 3-fold higher risk for a failed trial of labor compared with women younger than 40 years. In one scoring system, women younger than 40 years were given an extra point as a predictor for successful VBAC.2 Maternal race and ethnicity have been examined as a predictor for VBAC in the setting of trial of labor and have not generally been noted to be a strong predictor. However, in the recent Maternal-Fetal Medicine Unit (MFMU) Cesarean Registry, both Hispanic ethnicity (odds ratio [OR] 0.65; 95% confidence interval [CI], 0.59-0.72) and African American ethnicity (OR 0.69; 95% CI, 0.63-0.75) were associated with lower rates of successful trial of labor. Whether this is due to actual biologic reasons or rather ethnicity acting as a proxy for some other factor or factors remains to be elucidated. Birth weight Birth weight greater than 4000 g is associated with an almost 4-fold higher risk of cesarean birth among nulliparous women (OR, 2.3-3.7). Several studies have demonstrated a difference in VBAC rates between patients with a birth weight greater than 4000 g and those with a lower birth weight. The odds ratio for this risk factor ranges from 1.2-1.9. Consistent with these findings, several studies have demonstrated a higher failure of a trial of labor with increasing birth weight. Obstetric history Obstetric history is enormously important in terms of risk factors for a successful trial of labor. Predictors for increased success include a nonrecurring indication for prior cesarean delivery (eg, breech presentation, placenta previa) and prior vaginal delivery. A history of cephalopelvic disproportion (CPD), failure to progress, no prior vaginal deliveries, or a prior cesarean delivery performed in the second stage of labor are negative predictors of success in a subsequent trial of labor. Indications for prior cesarean delivery

Several studies have examined indications for prior cesarean delivery as a predictor of outcome in a subsequent trial of labor. In all studies, CPD had the lowest VBAC success rate (60-65%). Fetal distress (eg, nonreassuring fetal testing) had the second lowest success rate of VBAC (6973%). Nonrecurrent indications, such as breech birth, herpes, and placenta previa, were associated with the highest rates of success (77-89%). Failure to progress, CPD, or dystocia as indications for prior cesarean delivery are also associated with a higher proportion of patients not attempting a trial of labor after cesarean birth. In a meta-analysis of the existing literature prior to 1990, Rosen et al demonstrated that women whose prior cesarean delivery was performed for CPD were twice as likely to have an unsuccessful trial of labor. 3 Prior vaginal delivery Patients with a prior vaginal delivery have higher rates of successful VBAC compared with patients without a prior vaginal birth. Furthermore, women with a successful VBAC have a higher success rate in a subsequent trial of labor compared with women whose vaginal delivery was prior to cesarean delivery. In an unadjusted comparison, patients with 1 prior vaginal delivery had an 89% VBAC success rate compared with a 70% success rate in patients without a prior vaginal delivery. In comparisons controlling for confounding factors, odds ratios of 0.3-0.5 for rate of cesarean delivery are found when comparing patients with a prior vaginal delivery with those without prior vaginal delivery. Among patients with a prior VBAC, the success rate is 93% compared with 85% in patients with a vaginal delivery prior to their cesarean birth but no prior VBAC. These findings have been repeatedly validated by multiple studies. See Medscape CME activity Prior Successful Vaginal Birth After Cesarean Delivery Linked to Low Risk for Complications in Later Attempts. Cervical dilation at prior cesarean delivery Only one study carefully examines cervical dilation at prior cesarean delivery. In this study, the degree of cervical dilation in the prior delivery is directly associated with the likelihood of success in the subsequent trial of labor. For example, 67% of patients who were dilated 5 cm or less at the time of their delivery had a successful VBAC compared with 73% of patients who were dilated 6-9 cm. The success rate is much lower for patients whose labor arrested in the second stage; only 13% of patients who were fully dilated at the time of their prior delivery had a successful VBAC. In a similar study, patients who had their prior cesarean delivery in the first stage of labor had a lower rate of cesarean delivery than those who had their prior cesarean delivery in the second stage of labor. However, in this study, 66% of patients who had a cesarean delivery for dystocia in the second stage had a successful VBAC. Induction of labor Patients who undergo induction of labor are at a higher risk of cesarean delivery compared with women who experience spontaneous labor. This finding has also been observed in women with a prior cesarean delivery. Several studies have demonstrated that women who are induced in a trial of labor after cesarean delivery have a 2- to 3-fold increased risk of cesarean delivery compared with those who present with spontaneous labor. A recent study demonstrated that patients who were able to be induced with oxytocin had a significantly lower cesarean delivery rate compared with those induced with a Foley bulb.

Gestational age Similar to studies of mode of delivery and gestational age in women without a prior cesarean delivery, increasing gestational age is associated with a decreased rate of successful VBAC. Three potential factors are related to the association of increasing gestational age with an increased rate of cesarean delivery: increasing birth weight, increased risk of fetal intolerance of labor, and increased need for induction of labor. However, in a recent study that controlled for both birth weight and induction/augmentation of labor, gestational age of greater than 41 weeks was still associated with failed VBAC. Cervical examination on admission Not surprisingly, patients who present to labor and delivery with advanced cervical examination findings have a greater success rate of vaginal birth. Several components of the cervical examination have been investigated, including cervical dilation and cervical effacement. Not surprisingly, the more advanced the cervical examination finding is upon initial presentation, the higher the rate of successful VBAC. A 1997 Flamm et al study demonstrated that patients presenting with dilation greater than or equal to 4 cm had an 86% rate of VBAC. Interpregnancy interval The timing between pregnancies has recently become an interesting predictor for a number of obstetric outcomes, VBAC success among them. In one analysis, women who had an interpregnancy interval of more than 18 months had an 86% chance of VBAC success, while women whose interpregnancy interval was less than 18 months had a VBAC success rate of 79%. This difference was not statistically significant, and whether interpregnancy interval does have any effect on success or rather only has an effect on the risk for uterine rupture is unclear. Preterm delivery Preterm labor and delivery is one of the factors that deserves attention as it should be considered an opportunity to recounsel women about the risks and benefits of a trial of labor after cesarean delivery. In one large study by Quinones et al, 12,463 attempted a trial of labor and the VBAC success rates for the term and preterm groups were 74% and 82%, respectively (P < .001) with an aOR of 1.54 (95% CI 1.27-1.86) for preterm delivery. Additionally, a trend toward decreased risk of uterine rupture among preterm delivery gestations was also found (aOR 0.28, 95% CI 0.07-1.17).4 These data can certainly be used to counsel women with a prior cesarean who are in preterm labor. Gestational or pregestational diabetes Only one study of patients undergoing a trial of labor after cesarean delivery has examined the rate of success in patients with diabetes mellitus (DM). This study demonstrated that patients with either gestational DM or pregestational DM had a lower rate of successful trial of labor. This is not particularly surprising; however, further studies are needed to sort out the differences between gestational and pregestational DM and the interaction between DM and birth weight.

Risk Factors for Uterine Rupture

One of the most significant risks women face when considering a trial of labor is that of uterine rupture. This potentially fatal event may have significant maternal and neonatal sequelae. A threshold of acceptable risk has been established between risk of women with 1 prior cesarean delivery (0.5-1%) and women with a history of a prior classic cesarean delivery (6-12%). These latter patients, along with women who have had metroplasty surgery for uterine anomalies or myomectomies that have entered the uterine cavity, are discouraged from attempting a VBAC. Other patients who are at increased risk for uterine rupture include those who have had 2 or more hysterotomies, those who are treated with prostaglandin agents, and those undergoing induction of labor (seeTable 2). Table 2: Predictors of Uterine Rupture Open table in new window Increased Rate of Uterine Rupture Decreased Rate of Uterine Rupture Classical hysterotomy Two or more cesarean deliveries Single-layer closure Induction of labor Use of prostaglandins Short interpregnancy interval Infection at prior cesarean delivery Classical hysterotomy Unquestionably, practitioners do not feel safe allowing a patient who has had a prior classical hysterotomy (ie, a vertical incision that has extended above the insertion of the round ligaments) to undergo a trial of labor. Patients with a prior classical hysterotomy have a higher rate of uterine rupture in subsequent pregnancies. Because these patients can sustain a uterine rupture prior to labor, they are often delivered at 36-37 weeks' gestation. Although available data are limited, the risk of uterine rupture in this group of patients is estimated at 6-12%. Low vertical (Krnig) hysterotomy Spontaneous labor Prior vaginal delivery Longer interpregnancy interval Preterm delivery

Retrospective cohort studies have demonstrated that the risk of uterine rupture is no greater for patients who have had a vertical incision in the lower uterine segment than those who have had a transverse incision. The rate of uterine rupture from these studies is 0.8-1.3%. When comparing patients with prior Krnig hysterotomies to patients with low transverse incisions, no statistical difference exists in either univariate or multivariate analyses controlling for the confounding factors of obstetrical history, induction of labor, birth weight, and length of labor. Low transverse (Kerr) hysterotomy Most babies delivered abdominally are delivered through a transverse incision in the lower uterine segment (Kerr hysterotomy). In several large retrospective cohort studies, the reported rate of uterine rupture is 0.3-1% (see Table 3). Rates of 0.5-1% (1 in 200 to 1 in 100) are commonly used to counsel patients with no other additional risk factors.

Table 3: Rates of Uterine Rupture Open table in new window Study Miller, 1994 Flamm, 1994 Sample Size (N) Rates 10,880 5,022 63 uterine ruptures (0.6%)* 39 uterine ruptures (0.8%) 10 uterine ruptures (0.3%) 28 uterine ruptures (1%) 124 uterine ruptures (0.7 %) 128 uterine ruptures (0.9%)

McMahon, 1996 3,249 Shipp, 1999 Landon, 2004 Macones, 2005 2,912 17,898 13,331

*Includes unknown Unknown hysterotomy When an obstetrician cannot obtain an operative report of a patient's prior cesarean delivery, obstetric history may be helpful in determining the type of uterine incision. For example, a patient who underwent a cesarean delivery for a breech presentation at 28 weeks' gestation has a much higher risk of a vertical uterine incision than the patient at term with arrest of dilation. Because most cesarean deliveries are via low transverse hysterotomies, the risk of uterine rupture for patients with an unknown uterine scar is usually similar to that of patients who have had a prior transverse incision. Several studies examining this issue have demonstrated that the rate of

rupture for patients with an unknown uterine incision is approximately 0.6%. A case-control study of patients with and without uterine rupture did not find unknown hysterotomy to be a risk factor compared with low transverse hysterotomy.5 Number of prior cesarean deliveries Patients with more than 1 prior cesarean delivery are at increased risk of uterine rupture. The unadjusted rate of uterine rupture for patients with 2 prior uterine incisions ranges from 1.8-3.7%. A recent analysis demonstrated that when potential confounding variables (eg, prior vaginal delivery) are controlled for, patients who have had 2 prior cesarean deliveries have 5 times the risk of uterine rupture compared with patients who have had only 1 prior cesarean delivery (aOR, 4.8). This finding contradicted several earlier studies that did not control for confounding factors, most importantly prior vaginal delivery. More recently, a study that examined major complications overall found that while there was a statistically significant increase, the aOR was only 1.6. Single-layer uterine closure While traditionally the uterine hysterotomy had been closed in several layers, in the 1990s, physicians at many institutions began closing the Kerr hysterotomy in a single layer. Because the lower uterine segment is quite thin, a single layer often afforded adequate hemostasis. Several recent studies have compared women whose hysterotomy was closed in a single layer with those whose hysterotomy was closed in 2 layers. Adjusted odds ratios of 3 to 4 for uterine rupture has been estimated for those women who only have a single-layer closure. Prior vaginal delivery Prior vaginal delivery appears to be protective for subsequent uterine rupture. A 2000 study by Zelop et al demonstrated that patients with a prior vaginal delivery had a 0.2% rate of rupture compared with 1.1% for patients with no prior vaginal delivery. An adjusted odds ratio controlling for confounding factors was 6.2.6 No studies have compared the rate of uterine rupture in patients with a prior VBAC with those with a vaginal delivery before their prior cesarean delivery. These findings have been validated in subsequent studies, though the effect size has not been quite as large. Prior infection A recent study demonstrated that women who had an infection at the time of the cesarean delivery have an increased rate of uterine rupture in a subsequent trial of labor. The assumed causal mechanism is poor healing of the hysterotomy secondary to the infection. Labor While labor appears to be a risk factor for uterine rupture, many patients experience a uterine rupture prior to the onset of labor. In a large study using birth certificate data, one study found that the rate of uterine rupture prior to the onset of labor was 0.5%. Patients at greatest risk are those with prior classical hysterotomies. As a result of this potential risk, these patients are usually scheduled for delivery at 36-37 weeks' gestation. When counseling this group of patients, however, mentioning that scheduling an early repeat cesarean delivery does not eliminate the risk of uterine rupture entirely is important.

Induction of labor Induction of labor as a risk factor for uterine rupture has been examined over only the past 5 years. One large study, which did not control for confounding factors, demonstrated a uterine rupture rate of 2.3% in patients who had experienced induced labor. In several studies controlling for confounding factors, adjusted odds ratios were 2-4 for patients who were induced compared with those who presented in spontaneous labor. Despite these analyses, discerning whether induction of labor itself leads to uterine rupture or whether another risk factor (as yet unmeasured) is associated with both induction of labor and uterine rupture is difficult. When patients have an indication for induction of labor, the best course of management is to discuss the increase over their baseline risk of uterine rupture. Use of oxytocin In the only prospective randomized trial in women with a prior cesarean delivery, one study examined the use of oxytocin augmentation in early labor compared with expectant management. In this study, 5 uterine ruptures occurred in the augmentation group (5%) and none occurred in the expectant management group. Excessive use of oxytocin has been described as leading to an increased risk of uterine rupture. A 1993 study by Leung et al demonstrated an odds ratio of 2.7 for uterine rupture in patients who used oxytocin compared with those without oxytocin augmentation.5 However, this study included inductions and augmentation in both the latent and active phases. These confounding factors may have contributed to much of the difference because induction of labor alone has an increased risk. In more recent studies, oxytocin augmentation was associated with uterine rupture. 7,8 While the odds ratio was 2.3, it was not statistically significant in the former study (95% CI, 0.8-7.1); this is likely secondary to inadequate power. In the latter study, a similar odds ratio of 2.4 (95% CI, 1.53.9) existed. Because labor and delivery units use oxytocin widely, this oxytocin uterine rupture relationship deserves careful consideration; the relationship directly impacts management of patients. At this point, using oxytocin for induction and augmentation is probably advisable only when absolutely necessary. Use of prostaglandins Evidence regarding the use of prostaglandins for induction of labor remains scant. However, in the few trials that have been conducted, the trend is toward an increase in the rate of uterine rupture. In 1999, the use of prostaglandin E2 was demonstrated to have an adjusted odds ratio of 3.2 (95% CI, 0.9-10.9). This study controlled for induction of labor, which appears to be an independent risk factor. In 2001, Lydon-Rochelle et al demonstrated a 3-fold increase in the risk for uterine rupture when comparing patients induced with prostaglandins with those induced with oxytocin.9 In the 2004 study by Landon et al, this effect of prostaglandin induction versus other means was smallerless than 2-fold (OR 3.95 with prostaglandin, 2.48 without prostaglandin). 8 As in studies examining the risk of uterine rupture in patients undergoing induction of labor, patients who were treated with prostaglandins were likely to have other confounding variables that were not controlled. In particular, the prostaglandin misoprostol has been examined in small studies. In 1998, Wing et al reported a case series of 17 patients who were induced with misoprostol, in which 2 uterine ruptures occurred. These findings have led to the decreased use of prostaglandins for induction, particularly misoprostol. 10

Foley bulb Only one small study exists of patients with a prior cesarean being induced with the transcervical Foley bulb. In that study, the rate of uterine rupture was 1.1% with spontaneous labor, 1.2% with induction with amniotomy, and 1.6% with use of a transcervical Foley bulb. While this rate is lower than some of the reported rates with prostaglandins, whether the increase seen in patients requiring cervical ripening is due to the need for cervical ripening or the agents themselves is unclear. Interpregnancy interval Several studies have demonstrated that the shorter the amount of time between the cesarean delivery and the subsequent delivery, the higher the rate of uterine rupture. Commonly, thresholds of 18 and 24 months have been examined. Adjusted odds ratios range from 2.5-3 for an increased rate of uterine rupture in the women with less time between deliveries. The biologic plausibility here is related to the amount of time required for the uterine scar to heal completely. Twin gestations A recent study by Cahill et al revealed that while women with twin gestations are less likely to undergo a trial of labor after prior cesarean, they appear to be at no increased risk for uterine rupture.11 Other smaller studies examined the rate of uterine rupture in patients with twin gestation undergoing a trial of labor after cesarean delivery, and none of these studies demonstrated a frank rupture, although combining their data revealed 5 asymptomatic dehiscences in 151 patients.12,13,14 The rate of asymptomatic uterine dehiscence in patients undergoing a trial of labor after cesarean delivery is difficult to assess because it is not commonly investigated. Thus, while the overall power examining this issue in twins is not overwhelming, certainly no evidence suggests a higher risk of uterine rupture in these women. Mllerian anomalies In 1999, one small series by Ravasia et al examined patients with mllerian anomalies undergoing a trial of labor after cesarean delivery. In this series, 2 uterine ruptures occurred among 25 patients (8%). However, both patients with uterine rupture had undergone induction with prostaglandins; therefore, making any assessment about the relative risk of uterine rupture in this group of patients is difficult. The sample size in this study was certainly too small to consider particular types of uterine anomalies.15 Maternal and neonatal outcomes When counseling regarding the tradeoffs between a trial of labor and an elective repeat cesarean delivery, several factors should be weighed. As discussed above, the rate of success is important as it has been demonstrated that maternal outcomes are better with a successful trial of labor than elective repeat cesarean delivery but worse with a cesarean delivery after a failed trial of labor. A 2004 study by Landon et al found that the overall measure of morbidity was higher among women who underwent a trial of labor. However, among the 15,801 women who elected to have a repeat cesarean delivery, 2 maternal deaths were reported. Among the 17,898 women who underwent a trial of labor, no maternal deaths were reported due to the trial of labor or

uterine rupture. This difference was too small to be statistically significant; however, the risk of repeat cesarean delivery to maternal morbidity and mortality should be considered. 8 The other important factor to consider is the neonatal outcomes in the setting of a trial of labor or a uterine rupture. In a large population-based study from Scotland, the authors found that among patients who underwent trial of labor after cesarean delivery, of 15,515 cases, 7 perinatal deaths occurred due to uterine rupture for a rate of 4.5 per 10,000 women. This was compared with no perinatal deaths due to uterine rupture among women undergoing elective repeat cesarean delivery and a rate of 0.5 per 10,000 among women laboring with no prior cesarean delivery. More recently, a study demonstrated that of 15,338 patients at term undergoing a trial of labor, 2 neonatal deaths and 7 cases of hypoxic-ischemic encephalopathy occurred for rates of 1.4 per 10,000 and 4.6 per 10,000 trials of labor, respectively. 8 In their series, 114 uterine ruptures occurred among these patients, giving rates of 1.8% of neonatal death per uterine rupture and 6.2% of hypoxic-ischemic encephalopathy peruterinerupture. Finally, one important individual characteristic that may tip the scales for many women making the decision about whether to undergo a trial of labor is whether they wish to have future pregnancies beyond the current one. As discussed above, once a vaginal birth has been achieved, the chances of future success and the risks of uterine rupture both improve. Further, with each subsequent cesarean delivery, the risks of maternal morbidity and, potentially, maternal mortality increase. Thus, for a woman who wants more children, taking the risk of a trial of labor in the current pregnancy may hold more long-term benefits than the woman who is planning on a tubal ligation after delivery.

Management of Patients With Prior Cesarean Deliveries

Patients with prior cesarean deliveries require special management, both antenatally and in labor and delivery. Early in their prenatal care, catalog patients' preexisting risk factors for both successful VBAC and uterine rupture. If uncertain about the prior hysterotomy facts, obtain the operative notes from patients' cesarean delivery. When all obstetric history is obtained, counsel patients regarding the risks and benefits of undergoing a trial of labor after cesarean delivery, and plan the particular mode of delivery with patients. Again, some providers and hospitals have particular consent forms that must be signed at this point regarding a trial of labor after cesarean delivery. Once the patient presents to the labor and delivery unit and is in labor, going through the risks and benefits again of a trial of labor after cesarean delivery is advisable. Because of possible changes in the patient's status, these risks may have changed from the prenatal setting. For example, if she presents in active labor, it seems that both her chances of failed VBAC and risk of uterine rupture decrease. In contrast, if she is presenting for induction of labor, her chances of failed VBAC and uterine rupture both increase. Regarding management on labor and delivery, several practices can help minimize the maternal and neonatal risk. Per ACOG guidelines, have an obstetrician, anesthesiologist, and operating room team immediately available to provide an emergent delivery. Clinically, observe the patient closely for signs of uterine rupture. Harbingers of uterine rupture include the following: Acute abdominal pain, persistent beyond contractions A popping sensation

Palpation of fetal parts outside the uterus upon Leopold maneuvers Repetitive or prolonged fetal heart rate deceleration High presenting part upon vaginal examination Vaginal bleeding

Treat any of these findings as a possible uterine rupture until another source for the finding has been identified. Rupture requires immediate delivery.

Summary
Despite the risks (0.5-1% rate of uterine rupture), a trial of labor after cesarean delivery remains an attractive option for many patients and leads to a successful outcome in a high proportion of cases. In comparison, the alternative of elective repeat cesarean delivery is not without risks. In addition to the inherent risks that cesarean delivery has over vaginal delivery, patients may experience uterine rupture prior to the onset of labor. Certainly, as mentioned above, one component of counseling should include whether patients are interested in subsequent pregnancies after the current pregnancy. As noted above, 2 prior cesarean deliveries further increase the risks of VBAC in a subsequent pregnancy, so for the future pregnancy, having had a successful VBAC offers protection after undergoing the risk in the current pregnancy. The decision to undergo a trial of labor after cesarean delivery is an individual one that should be based on careful, thorough counseling. Maternal characteristics and obstetric history can provide a patient a rough estimate of her chance of a successful trial of labor. This same obstetric history can be used to estimate a patient's risk of uterine rupture. If possible, avoid induction of labor because induction of labor decreases the probability of success and increases the chance of uterine rupture in a trial of labor after cesarean delivery. Counsel patients who elect to undergo a trial of labor after cesarean delivery to be evaluated early in labor and to manage the pregnancy in a hospital setting in which uterine rupture can be both recognized and managed expediently.

About . com

Vaginal Birth After Cesarean - A Good Idea?

By Robin Elise Weiss, LCCE, About.com Guide

See More About: c-section vbac childbirth class Sponsored Links Having a Cesarean?Information To Ease Your Worries Make Sure You Get The Right Advicewww.C-SectionAdvice.com How To Get Pregnant FastI Stopped these common mistakes and got Pregnant almost immediately!www.PersonalPathtoPregnancy.net Fjordblink Birth PoolsErgonomic hospital Birth Pools with Raising/Lowering systemwww.fjordblink.com Pregnancy Ads Pregnancy and BirthBirth VideoBirth LaborBirthing Class VideoNatural Birth Class There used to be an old adage, "Once a cesarean always a cesarean."

Nowadays practitioners, women, and researchers are finding that this is not always true. Current research shows us that the reasoning behind the adage, that a uterus that had a previous incision was too weak to withstand labor is not a fact. In fact, over 86% of women who have had a previous cesarean can have a subsequent vaginal birth. Why would I want a vaginal birth? A vaginal birth has many advantages over a planned repeat cesarean surgery. Reduction in Maternal complications (infection, lower blood loss, bowel injury, etc.) Reduction in Iatrogenic Prematurity Reduction in the cases of Persistent Pulmonary Hypertension Labor prepares the baby for extrauterine life Prevention of surgery related fetal injuries (lacerations, broken bones) VBAC results in fewer fetal deaths than elective repeat cesareans Quicker recovery for Mother

What about uterine rupture? This is a common fear among women who have had a previous cesarean. Most of this fear dates back to when the incisions of the original cesarean were of the classical variety (vertical incisions). Nowadays, most incisions are the low transverse type. There are two types of uterine rupture: complete and incomplete. Complete uterine rupture is very unlikely today, for a variety of reasons. One is that when we use Pitocin, if needed, during a labor, we regulate the amount that goes in. In other times it was given IV to a woman and allowed to flow freely. These have also decreased due to some obstetrical practices being abandoned, like high forceps, internal version, etc. And the final reason is because of the rarity of the classical incision. A complete rupture occurs in far less than 1% of women attempting VBAC. Incomplete rupture (dehiscence) occurs about 1-2% of the time. However, these women are usually asymptomatic, and neither mother nor infant require any assistance. "True uterine rupture is often sudden and associated with pain, blood loss and fetal morbidity. It is most commonly seen in spontaneous or traumatic rupture of the unscarred uterus. It also has been associated with classic uterine scars, often occurring without. Conversely, uterine dehiscence in partial separation of the uterine wall that is usually asymptomatic and rarely contributes to fetal or maternal morbidity. This is often the type of separation seen in lower segment scars, and usually occurs during labor. Often asymptomatic windows are incidentally noted at the time of repeat cesarean section," says Dr. Robert Silver, in OB/GYN Secrets, edited by Wilkins-Haug and Fredrickson. How do I know if I'm a candidate for a vaginal birth? The only criteria you must meet in most circumstances is that you are willing to have a vaginal birth, you have a lower segment incision on the uterus (You have to ask the physician who did the surgery because the outside incision is not always the same as the internal incision.), and you have a non- repeating factor for the previous cesarean surgery. What do you need to know to attempt a vaginal birth after a previous cesarean?

There is basically no difference. Women who are having a vaginal birth after a cesarean will be treated the same as other pregnant mothers, with the exception of possibly more monitoring during labor, depending on the physician. You may still have pain medications and medications to induce labor (Pitocin, prostaglandin, etc.). I encourage you to read as much as possible about labor, birth, and VBAC as possible. Hiring a doula or labor support person might be useful. Expect that you may have certain feelings come up in labor (fear or giving birth, being stuck where you were with the previous cesarean, etc.) and be prepared to handle them. Consider going to support groups for women who have had a cesarean, like the International Cesarean Awareness Network. Acog education, woman health

A cesarean birth is the delivery of a baby through an incision (cut) made in the mothers
abdomen and uterus. Doctors used to believe that if a woman had one cesarean delivery, all other babies she had should be born in the same way. Today, doctors know that many women who have had a cesarean delivery can later safely give birth though the vagina. This is called vaginal birth after cesarean (VBAC) delivery. VBAC can be a safe option for many women. However, it is not the right choice for all women, and there are some risks. This pamphlet will explain why you may want to think about trying VBAC what risks are involved whether VBAC is right for you VBAC can be an option for many women. Whether VBAC is a good choice for you depends on many factors.

Reasons to Consider VBAC

Of women who try VBAC, 6080% succeed and are able to give birth vaginally. The success rate varies depending on the reason for the previous cesarean delivery. There are some reasons why a woman may want to try VBAC over cesarean delivery: No abdominal surgery Shorter hospital stay Lower risk of infection Less blood loss Less need for blood transfusions

Risks of VBAC VBAC has risks as well as benefits. With VBAC, there is a risk that the cesarean scar may rupture (tear) during delivery. There also is a risk that the uterus will rupture. Although a rupture of the uterus is rare, it is serious and may be harmful to you or your baby. If your doctor thinks you are at high risk for rupture of the uterus, VBAC should not be tried.

Sometimes, when a woman chooses VBAC, she may have to switch to a cesarean delivery during the course of labor. This can happen if problems arise without warning or worsen during childbirth. If problems arise, you may need an emergency cesarean delivery. There is a higher risk of infection for the woman and her baby when she tries VBAC and then gives birth by cesarean delivery. Is VBAC Right for You? In deciding if you can try VBAC, a key factor is the type of incision you had in your uterus for your previous cesarean delivery. Some types are more likely to rupture than others. For cesarean birth, one incision is made in your abdomen and another incision is made in your uterus. Any incision makes a scar. You cannot tell what kind of incision you had in your uterus by looking at the scar on your skin. Your doctor should be able to tell which kind of incision you had by looking at your medical records, if they are available. If your doctor does not know what type of incision you had, you may not be a candidate for VBAC. There are three types of incisions: 1. Low transverseA side-to-side cut made across the lower, thinner part of the uterus 2. Low verticalAn up-and-down cut made in the lower, thinner part of the uterus 3. High vertical (also called classical)An up-and-down cut made in the upper part of the uterus Women with high vertical incisions have a much higher risk of rupture. Women who have had more than one previous cesarean delivery also may have an increased risk of rupture. VBAC may not be a good option for them. Women who have had at least one vaginal delivery, in addition to the previous cesarean delivery, are more likely to succeed with VBAC. Other Factors to Consider Other factors may affect whether VBAC is an option for you. These include problems with theplacenta, problems with the baby, or certain medical conditions during pregnancy. A woman can still try VBAC when her pregnancy continues past her due date. However, the success rate for vaginal birth after cesarean delivery is decreased if there is a need to induce labor (use drugs or other means to help labor begin). Vaginal birth after cesarean delivery is not performed in some hospitals. The hospital or other facility where the baby is delivered should be equipped to handle an emergency cesarean delivery. In many ways, women who attempt VBAC will go through some of the same things that other women experience. For instance, fetal monitoring will be used to check on the health of the baby, and an epidural can be given for pain relief. Finally... VBAC can be an option for many women. Whether VBAC is a good choice for you depends on many factors.

No labor or delivery is risk-free. Both repeat cesarean births and VBAC have risks and benefits. When considering VBAC, you need to know the risks. Weigh those risks against the benefits before you decide. Your doctor will help guide your decision to do what is best for you and your baby.

Obgyn net

Delivery after Caesarean Section Billings MT

At present there is no method to predict which patients are likely to sustain uterine rupture which is the main risk of trial of scar and may occur even with optimum management of intrapartum care. In order to make trial of labour safer, it is important to have a high index of suspicion such that detection of uterine rupture is not delayed and early detection is followed by rapid intervention to improve maternal and fetal outlook. O. Tamizian and S. Arulkumaran Derby City General Hospital, Derby, United Kingdom Vaginal deliver rates after previous caesarean section have been on the increase through the 1980s and 1990s but even at the dawn of the 21st century, trial of scar remains a controversy in obstetric care. Generations of western obstetricians were brought up with the adage once a caesarean, always a caesarean coined by Cragin in 19161, ironically in an effort to stress that one of the risks of a primary caesarean section was the more dangerous repeat operation that may be required as a consequence in the future. In the early 20th century caesarean sections were performed through a vertical classical incision extending from the lower segment up to the fundus. The introduction of the transverse lower segment incision by Kerr in the 1920s led to decline of the classical operation. Several studies performed in the 1960s and 1970s2 along with larger studies performed in the 1980s3,4 confirmed the safety of vaginal delivery after previous caesarean section. A large study comparing the risks of trial of labour to elective caesarean section found that the length of hospital stay, postpartum blood transfusion rate and incidence of postpartum fever were higher I the elective caesarean section group5. This finding was the result of the fact that 75% of the trial of labour group delivered vaginally. However, when the elective caesarean section group is compared to the failed trial of labour group, maternal morbidity is indeed higher with caesarean section following failed trial of labour6. In a well designed study involving 6,138 women McMahon et al6 reported increased morbidity amongst women with caesarean section following failed trial of labour compared to repeat elective caesarean section. There was increase incidence of uterine rupture, operative injury and hysterectomy, with the all complications rising twofold and major complications fivefold. The success rates for vaginal delivery after caesarean section when all indications for the primary operation are considered, is approximately 75%3,4,6, approaching, in many hospitals the likelihood of a vaginal birth for a nulliparous patient. A meta analysis of 29 studies found that the success rate for vaginal delivery after caesarean ranged from 67% for patients with prior failure to progress in labour, to 85% where the indication for the primary operation was breech presentation, with all indication for previous caesarean section being associated with success rates of vaginal delivery that would make trial of labour appropriate7. Jongen et al8,

in a study of 103 patients with prior caesarean section for failure of descent in the second stage, 80% managed to have a vaginal birth. The study group included 55 women with a previous failed attempt at instrumental delivery and 41 of these patients also achieved a vaginal birth. The risk of uterine rupture is approximately 1% with a low transverse uterine incision, while it may be as high as 10% with a prior classical uterine incision and thus in the latter group trial of labour is generally contraindicated. The risk of uterine rupture following two transverse lower segment uterine incisions appears to be around 1.8% in a large study where the uterine rupture rate after one precious caesarean section was reported as 0.6%9. Data on the risk of uterine rupture is limited on patients with more than two previous cesarean sections but appears to be in the same region as that for patients with 2 previous caesarean sections. Large studies looking at prostaglandin gel110, and oxytocin11, have indicated that they are safe to use in women with a previous caesarean section. It would however be prudent to exercise caution when inducing or augmenting labour in patients with a uterine scar. Complete uterine rupture involves all the layers of the uterus including serosa with complete or partial fetal extrusion in 50% of cases and carries significant maternal and fetal risks. Hysterectomy is required in 10% of cases of uterine rupture and although maternal deaths have been recorded, they are thankfully extremely rare. The principal fetal risk following uterine rupture is asphyxia, but uterine rupture per se, does not carry dire consequences for the fetus. Perinatal outcome appears to be linked to the time interval from the onset of the ominous FHR patterns to delivery of the infant and infants suffering permanent brain injury or death when this window exceeds 18 minutes12 with fetal heart rate abnormalities such as prolonged deceleration or bradycardia or repetitive severe variable decelerations providing the earliest indication of uterine rupture13. The risk of asphyxia related neurological injury due to uterine rupture appears to be approximately 1/2500 to 1/5000 trials of labour3,5,9. Central to the debate of mode of delivery after previous cesarean section, are the prospective mothers wishes. Women are less likely to accept risks to their baby than their obstetricians and are no longer the passive recipient of care14. Maternal request figures more and more as an indication for repeat cesarean section and the informed consumers choice may still be a repeat cesarean section regardless of the likelihood and advocated benefits of a successful trial of vaginal delivery. At present there is no method to predict which patients are likely to sustain uterine rupture which is the main risk of trial of scar and may occur even with optimum management of intrapartum care. In order to make trial of labour safer, it is important to have a high index of suspicion such that detection of uterine rupture is not delayed and early detection is followed by rapid intervention to improve maternal and fetal outlook. Neither vaginal delivery after cesarean section nor repeat cesarean section are without risks. In order to eliminate the risks of either, the way forward would be to reduce the primary cesarean section rate by revisiting the appropriateness of the indications of primary cesarean sections. C-Section or Vaginal Birth: Does One Preclude the Other? (HealthDay News) -- Having a baby is always full of fateful decisions. One is whether to have an elective cesarean section. Even more debatable is the decision to have a vaginal birth after having had a cesarean

for the previous baby. Both have roiled the world of mothers-to-be and obstetricians. And while there's been a lot of argument, it's fair to say more study is needed before a solid conclusion can be made. A generation ago, there was little or no debate. Women rarely chose a cesarean but had one only if necessary, usually a life-saving alternative. From that point on, the mantra among obstetricians was once a cesarean always a cesarean. Anything else was generally deemed much too risky. But then two things happened. First, the rate of cesareans climbed sharply, from five percent in 1970 to 26 percent in 2002, often for the convenience of the mother or for the schedule of the obstetrician. A recent study in the British Medical Journal found that first-time cesareans in women with no apparent medical need -- a so-called elective cesarean -- rose by 67 percent in the U.S., from 3.3 percent to 5.5 percent overall, from 1991 to 2001. Meanwhile, obstetricians realized that vaginal birth after cesarean (VBAC) wasn't so risky after all, and it was at least worth a try for most women. So VBAC, a new acronym, entered the medical lexicon, along with the ubiquitous c-section. In the 1990s, VBAC became the way to go for large numbers of women. About 31 percent elected trial by labor in deliveries after a c-section by 1998, up from three percent in 1981. VBAC became nearly as trendy for mother and child as breast feeding. Then, two more things happened. Malpractice suits began to send insurance premiums soaring for obstetricians who had joined the VBAC parade for their patients. And then studies suggested that while VBAC was much less risky than doctors used to believe, it was not without risk. By 2002 these factors had an impact. The VBAC rate fell to 12.6 percent in 2002. Many doctors stopped doing VBAC because of liability fears. A survey by the American College of Obstetricians and Gynecologists (ACOG) revealed that 14.8 percent of its members no longer offered VBAC. At the same time, the American College of Obstetricians and Gynecologists issued a statement on the ethics of how doctors can advise women on to have elective cesareans in the absence of solid safety data. The most recent big study, published in December in the New England Journal of Medicine, reported that 587 of 588 women will do just fine in a trial by labor after a previous VBAC. But that 1-in-588 th delivery could have serious problems for mother or child, mostly uterine ruptures, despite special precautions that are taken for a VBAC delivery. Of the women who underwent trial of labor, 0.7 percent had uterine rupture, while 12 infants had brain damage from lack of oxygen, seven of them following uterine rupture; two babies died. This translates into an absolute risk of 0.46 per 1,000 women For women undergoing trial of labor, the overall risk of one of these serious adverse outcomes at term is one in 2,000 trials of labor," said Dr. Mark B. Landon of Ohio State, the study chairman. "For many women, that level of risk is clearly acceptable, with the benefit being a potential vaginal birth with shorter recovery, less hospitalization, and the satisfaction that goes with vaginal delivery itself. For other women, any level of potentially preventable fetal risk is unacceptable." On the other hand, the study did not assess the potential risks of repeat c-sections. Authorities at a meeting in New York, sponsored by the Maternity Center Association, reported that women who have an elective c-section are at a significantly higher risk of pain after surgery, infection, rehospitalization and problems with subsequent pregnancies. In short, an elective cesarean is not necessarily innocuous, equal to a first-time vaginal birth...

Babies delivered by c-section are less likely to be breast-fed, seem to have a higher risk for asthma, and, if born before the 39th week of pregnancy, are more likely to have respiratory problems than babies delivered vaginally, according to the speakers. "Choosing whether to have a vaginal delivery or an elective caesarean section is based on the premise that these two choices are essentially equivalent, but this is simply not true," said Eugene Declercq, one of the panelists and a professor of maternal and child health at the Boston University School of Public Health. As to VBAC, a government study noted that "patients, clinicians, insurers and policymakers do not have the data they need to make truly informed decisions about appropriate delivery choices following one of the most common surgical procedures performed on women." Kehamilan dan persalinan dengan parut uterus
Written by Administrator Monday, 30 November 2009 02:19

Firman F. Wirakusumah Tujuan Instruksional Umum (TIK) : Memahami kehamilan dan persalinan dengan parut uterus sehingga dapat mengenal kasus-kasus kehamilan dan persalinan dengan parut uterus dan dapat mengelola sampai merujuk tepat waktu ke pusat pelayanan kesehatan yang memadai. Tujuan Perilaku Khusus (TPK) : 1. Mendefinisikan kehamilan dan persalinan dengan luka parut uterus 2. Mengidentifikasi riwayat dan pemeriksaan pada ibu hamil dengan parut uterus 3. Mendiskusikan mekanisme terjadinya komplikasi yang mungkin timbul selama kehamilan dan persalinan. 4. Berkomunikasi dengan ibu dan keluarganya tentang rencana persalinan 5. Menjelaskan perbedaan antara uterus normal dan uterus dengan luka parut pada kehamilan dan persalinan 6. Memberikan petunjuk kepada ibu hamil dan dalam persalinan dalam merencanakan pemeriksaan kehamilan dan persalinannya 7. Menjelaskan perihal cara tepat memilih rencana keluarga berencana. Cragins dictum (1916) once a cesarean, always a cesarean is obsolete. This dictum should be changed into once a cesarean, always a hospital delivery (Van Roosmalen) 1-3 Pendahuluan Ditahun 70-an dan awal 80-an seksio sesarea meningkat cepat. Ditahun 90-an dilaporkan didunia ini wanita melahirkan dengan seksio sesarea meningkat 4 kali dibanding 30 tahun sebelumnya 4,5. Sebabnya multifaktorial, termasuk diantaranya meningkatnya indikasi seksio sesarea ulang pada kehamilan dengan parut uterus. Sampai saat ini belum ada hasil penelitian berdasarkan Randomised Controlled Trials (RCT) untuk

menilai keuntungan atau kerugian antara persalinan pervaginam dan seksio sesarea ulang pada kasus kehamilan dengan parut uterus 6. Terdapat 4 indikasi utama untuk melakukan seksio sesarea yaitu; 1) distosia 2) gawat janin 3) kelainan letak dan 4) parut uterus. Kehamilan dan persalinan setelah wanita melahirkan dengan seksio sesarea akan mendapat risiko tinggi terjadinya morbiditas dan mortalitas yang meningkat berkenaan dengan parut uterus. Ditahun 80-an seksio sesarea atas indikasi parut uterus berkisar 25-30% dari angka kenaikan seksio sesarea di Amerika Serikat 4. Dilihat dari angka kejadian seksio sesarea dilaporkan di USA, indikasi parut uterus 35%, Australia 35%, Skotlandia 43%, Perancis 28% 5-10. Ditahun 90-an angka seksio sesarea atas indikasi parut uterus menurun dengan di kembangkannya persalinan pervaginam pada parut uterus,Vaginal Birth After Cesarean (VBAC) atau dikenal pula sebagai Trial of Labor After Cesarean (TOLAC) 6-11. Di USA pada awal abad 21 ini, dari 10 wanita yang melahirkan terdapat 1 wanita dengan parut uterus 12. Di Bandung (RSHS) seksio sesarea dengan parut uterus adalah 10%, tetapi indikasi awal tidak selalu karena parut uterus 13. Angka kejadian seksio sesarea primer dan VBAC di Amerika Serikat 1989-1998 dilaporkan sbb.: seksio sesarea 20,7-22,8% dari seluruh persalinan hidup, seksio sesarea primer 14,6-16,1% pada wanita yang belum pernah mendapat seksio sesarea dan 18,9-28,3% wanita melahirkan pervaginan dengan parut uterus (VBAC) 6,10,14-18. Tabel 1. Indikasi seksio sesarea pada kurun waktu tahun 90-an di 4 negara maju Indikasi Norwegia Scotlandia Swedia Parut uterus Distosia Gawat janin 94,3 86,7 79,6 34,6 15,1 4,0 47,1 66,3 22,8 35,4 3,1 Amerika Serikat 80,5 83,3 59,7 36,6 4,6

Sungsang 60,8 31,6 42,5

Lain-lain 4,7

Jumlah 12,8 14,2 10,7 23,6 Sumber : Notzon 5. Tabel Angka kejadian persalinan dan seksio Rumah Sakit Pendidikan di Indonesia tahun 2006 Nama Rumah Sakit Jumlah Persalinan Seksio Sesarea Pertama kali RS dr.Wahidin Sudirohusodo Makassar 790 288 (36,5%)

sesarea

2. di

pada parut uterus 42 (5,3%)

RS dr Kariadi Semarang 1632 500 (30,6%) 25 (1,5%) RS dr.Hasan Sadikin Bandung 2103 880 (41.8%) 67 (3,2%) RS Prof.dr.RD Kandou Manado 2450 626 (25,6%) 122 (5,0%) RS Sanglah Denpasar 3541 852 (24,0%) 331 (9,3%) _______________________________________________________________________ _ Sumber : Laporan Tahunan Bagian Obstetri dan Ginekologi (komunikasi pribadi). Kehamilan dengan parut uterus Konseling wanita hamil dengan parut uterus umumnya adalah sama seperti kehamilan normal, hanya yang harus diperhatikan bahwa konseling ditekankan pada: 1. persalinan harus dilakukan di rumah sakit dengan peralatan yang memadai untuk kasus persalinan dengan parut uterus 2. konseling mengenai rencana keluarga berencana untuk memilih keluarga kecil dengan cara kontrasepsi mantap. Persalinan dengan parut uterus Diktum dari Cragin (1916) bahwa sekali dilakukan Seksio Sesarea selanjutnya persalinan harus dilakukan seksio sesarea ulang. Diktum ini sekarang sudah tidak dipakai lagi, 1-3,13 dahulu seksio sesarea dilakukan dengan sayatan vertikal pada korpus uteri (secara klasik), sekarang umumnya memakai tehnik sayatan melintang pada segmen bawah rahim. Kejadian dehisens parut uterus dan uterus ruptur meningkat dengan bertambahnya jumlah seksio sesarea pada kehamilan berikutnya. Seksio sesarea elektif dilakukan pada wanita hamil dengan parut uterus yang akan melakukan sterilisasi Tubektomi. Konseling mengenai keluarga berencana perlu ditekankan, karena morbiditas dan mortalitas meningkat pada wanita dengan parut uterus, makin sering bersalin dengan seksio sesarea makin besar bahaya terjadinya rupura uteri. Seksio sesarea elektif dilakukan pada kehamilan cukup bulan dengan paru-paru janin yang matur dan dianjurkan pula dilakukan tubektomi partialis19. Dibeberapa rumah sakit dapat dilakukan induksi/augmentasi persalinan dengan parut uterus dengan oksitosin. Induksi atau augmentasi persalinan pada parut uterus menggunakan oksitosin atau derivat prostaglandin sangat berbahaya. Tidak dianjurkan untuk melakukan induksi atau augmentasi pada kasus persalinan dengan parut uterus 20,21. Hal yang perlu diperhatikan untuk menentukan prognosis persalinan pervaginam dengan parut uterus adalah: 1. 2. 3. 4. Jenis sayatan uterus yang telah dilakukan pada operasi terdahulu Indikasi operasi seksio sesarea terdahulu Apakah jenis operasi terdahulu adalah seksio sesarea elektif atau emergensi Apa komplikasi operasi terdahulu

Dilaporkan angka kejadian ruptura uteri pada parut uterus cukup tinggi, terutama di negara sedang berkembang. Angka kejadian di negara berkembang hanya 0-2%, sedangkan di negara sedang berkembang dilaporkan sampai 4-7% 3,13,22. Masalahnya berkait dengan kurangnya akses wanita untuk melahirkan di rumah sakit. Hal yang perlu diperhatikan dalam antisipasi terjadi komplikasi kehamilan maupun persalinan ini adalah : 1. Selama kehamilan perlu konseling mengenai bahaya persalinan pada kasus parut uterus. 2. Tidak diperkenankan ibu bersalin di rumah atau Puskesmas pada kasus parut uterus. Perlu konseling bahwa risiko persalinan untuk terjadinya dehisens dan ruptura uteri adalah tinggi, sehingga perlu dilakukan rujukan segera. 3. Di rumah sakit perlu fasilitas yang memadai untuk menangani kasus seksio sesarea emergensi dan dilakukan seleksi ketat untuk melakukan persalinan pervaginam dengan parut uterus.

Upaya untuk menekan angka kejadian seksio sesarea yang tinggi ini perlu dibuat protokol pertolongan persalinan yang baik misalnya, dengan melaksanakan 1) manajemen persalinan aktif dan 2) dibuat prosedur tetap (SOP) untuk kasus parut uterus. Persalinan pervaginam pada parut uterus (Vaginal Birth After Cesarean/VBAC atau Trial of labor After Cesarean/TOLAC). Dengan berkembangnya tehnik pertolongan persalinan, tindakan persalinan pervaginam pada parut uterus meningkat. Dahulu ditakutkan terjadinya ruptura uteri. Di Amerika Serikat angka kejadian VBAC meningkat dari 18,9% menjadi 28,3% dalam kurun waktu tahun 90-an, gambaran ini memperlihatkan bahwa penanganan persalinan pervaginam lebih diutamakan pada akhir-akhir ini 10-12,15. Prosedur persalinan pervaginam dengan parut uterus : Menurut ALARM International 23 : Hal dasar yang perlu diperhatikan ; 1. Identifikasi pasien apakah memenuhi syarat untuk dilakukan pertolongan persalinan pervaginan. 2. Menjelaskan dengan cermat mengenai rencana pertolongan persalinan dengan diakhiri penandatanganan persetujuan pasien/keluargainformed consent. 3. Persiapkan pemantauan ibu dan janin dalam persalinan secara terus-menerus ( continuous electronic monitoring ). 1. Dipersiapkan sarana operasi segera untuk menghadapi kegagalan VBAC/TOLAC. Pemilihan pasien ;

1. Kenali jenis operasi terdahulu 2. Bila mungkin mengenal kondisi operasi terdahulu dari laporan operasinya (adakah kesulitan atau komplikasinya) 3. Dianjurkan VBAC dilakukan hanya pada uterus dengan luka parut dari sayatan transversal Segmen Bawah Rahim (SBR). Kontra indikasi VBAC ; 1. 2. 3. 4. 5. 6. 7. 8. 9. Kontra indikasi dilakukan persalinan pervaginam secara umum Luka parut uterus jenis klasik Jenis luka T terbalik atau jenis parut yang tidak diketahui Luka parut pada otot rahim diluar SBR Bekas uterus ruptur Kontra indikasi relatif misal, panggul sempit relatif Dua atau lebih luka parut transversal di SBR Kehamilan ganda Presentasi bokong

Pertolongan persalinan dilakukan sesuai dengan standar prosedur tetap yang dibuat sesuai dengan kondisi sarana pelayanan persalinan setempat. Perlu mendapat perhatian ; 1. Observasi perjalanan persalinan dengan baik, kondisi ibu dan kesejahteraan janin terpantau. 2. Bila perlu memberikan analgesia 3. Ingat kemungkinan terjadi uterus ruptur Cara tepat memilih rencana keluarga berencana : Konseling Keluarga Berencana perlu diberikan sejak awal kehamilan. Untuk menghindari terjadinya komplikasi berat dianjurkan memakai kontrasepsi mantap, terutama untuk persalinan pada luka parut uterus ke tiga kalinya. Penutup Persalinan pervaginam pada kasus parut uterus dipilih karena, dari hasil penelitian yang ada persalinan pervaginam tidak meningkatkan kematian ibu dan anak walaupun dilaporkan adanya kenaikan morbiditas. Hal ini dapat ditekan dengan penanganan yang baik.

Is Vaginal Delivery After C-Section Safe?

Study Shows Uterine Rupture, Infant Brain Damage in Only Small Number of Cases By Jeanie Lerche Davis WebMD Health News Dec. 15, 2004 -- Having a vaginal delivery after a prior cesarean section is slightly riskier to both the mother and her baby than having a planned C-section.

It's an issue that's been debated for several years now. In fact, the numbers of vaginal births in women that have had prior cesarean deliveries has fallen steadily to 13% in 2002. Reports of uterine rupture because of vaginal delivery attempts in women with prior cesareans and their catastrophic consequences may have led to these declines. A comprehensive study, published earlier this year, showed that almost 75% of women who attempted labor after a prior C-section had a successful vaginal delivery. The study showed that the complication rate was lower in these women than in those who had planned surgical deliveries. In a planned surgical (cesarean) delivery, women do not go into labor in order to deliver a baby. The researchers estimated the risk for serious newborn complications was one in 2,000 deliveries when vaginal birth after C-section was attempted. Uterine rupture is the biggest concern with vaginal births after cesarean delivery (VBAC), but the complication occurred in less than 1% of women who took part in the study.

Vaginal Birth After C-Section or Planned C-Section?

The study, which appears in this week's New England Journal of Medicine, shows that VBAC carries a greater risk than planned C-sections -- but those risks are low, reports researcher Mark B. Langdon, MD, with the National Institute of Child Health and Human Development MaternalFetal Medicine Units Network. Langdon's study results "are, arguably, 'as good as they can get' in the United States," writes Michael F. Greene, MD, in an accompanying editorial. Greene is a professor of obstetrics and gynecology with Massachusetts General Hospital in Boston. The strength of large studies like Langdon's "is that they report 'real world' results," he adds. Langdon's study involved women who had prior C-sections. There were 17,900 women who attempted a vaginal delivery after going into labor and 15,800 who had a planned cesarean delivery without labor. In women who underwent a vaginal delivery after going in to labor: 0.7% women had uterine rupture. 1.7% needed blood transfusions versus 1% who had repeat C-sections. 3% had endometritis, an inflammation of the uterine lining that can put women at risk of death from septic shock, a rare occurrence. In women who had planned C-sections, 1.8% had endometritis.

These adverse events were "significantly more common" after a trial of labor than with a planned C-section, he writes. This was especially true when labor had been unsuccessful, he adds. For infants, frequency of brain or nervous system damage or death was "significantly greater" for infants born via VBAC, reports Langdon. However, the risks were still small: Two infants with brain damage died during vaginal delivery. Overall, his data indicates the risk of labor and a vaginal delivery after a prior C-section is small but greater than with planned C-section, Langdon writes. His hope is that the information will help women make the sometimes difficult choice between vaginal delivery and planned C-section. Overview

Though once valid, the belief that women who have delivered via cesarean section (c-section) are not eligible for later vaginal delivery is no longer true. Vaginal birth after cesarean section (VBAC) has become more common as risks to mother and infant have been reduced and because of the benefits. During c-section, an incision is made in the abdominal and uterine walls, the amniotic sac (bag of waters) is ruptured, and the doctor removes the infant through this incision rather than vaginally. In certain circumstances, c-section requires a vertical incision through the abdominal and uterine walls, which is more prone to tearing during subsequent deliveries than the scar left by the current technique of a low transverse (horizontal) incision.

Advertising Disclaimer

Incidence and Prevalence According to the Centers for Disease Control and Prevention (CDC), more than 29% of births in the United States are by c-sections, and repeat cesareans account for approximately one-third of these. According to the World Health Organization, a rate of 10% to 15% may be more desirable. Repeat c-section is not always necessary; successful VBAC could decrease these numbers, but not all women who are eligible attempt it. In 1995, only 27% (about 76,000) of candidates attempted vaginal birth after cesarean section. The increase in c-sections over the past decades is attributed to many factors including: fetal monitoring, which indicates when the fetus is in danger, medical-legal reasons, and delivery of breech infants.

C-section rates are also higher for older women with private medical insurance and higher income than for other groups. Who are candidates? Candidates for VBAC are women who: have had not more than two horizontal (transverse) incisions in the uterus (in contrast to the previously used vertical incision in the uterus) and have no history of uterine rupture.

Some candidacy guidelines (e.g., the ACOG Practice Bulletin) recommend that a pregnant woman undergoing VBAC should have an obstetrician and anesthesiologist immediately available to perform a c-section in the event of uterine rupture, which can threaten the lives of the mother and infant. Home births are not recommended for VBAC candidates. Contraindications Women who have had a vertical incision (or "classic incision") are not considered candidates for VBAC because of their increased risk for uterine rupture. Inadequate

obstetrical operating facilities and medical staff (e.g., anesthesiologist, ob/gyn) also indicate that a repeat c-section might be advisable. It is widely accepted that women who have had a uterine rupture in the past should have a c-section rather than attempt vaginal delivery. Common signs of uterine rupture during labor include: abnormal fetal heart patterns, abdominal pain, and vaginal bleeding.

Risks A cesarean delivery is major surgery, with all of the associated risks. When successful, VBAC is safer than c-section. VBAC is associated with a small risk of uterine rupture, but it is considered to be a safe option for some by the American College of Obstetricians and Gynecologists (ACOG). The uterus is a hollow, muscular organ. A uterine rupture is a surgical emergency that occurs during labor and sometimes before labor starts. The uterine wall tears at the site of a prior surgical incision and sometimes tears as a result of weak uterine muscle tissue (caused by multiple pregnancies or infection). The infant may be expelled from the uterus into the mother's abdominal cavity, which can result in infant brain damage or death.
Advertising Disclaimer

The incidence of uterine rupture with VBAC in a mother who has had a low transverse incision is approximately 0.2 - 1.5%. Accompanying the elevated risk of uterine rupture is an increased risk for hysterectomy (surgical removal of the uterus). However, most cases are managed by controlling the bleeding and repairing the tear surgically. Also, there are indications that a failed attempt at VBAC followed by a c-section increases the rate of infection in infants and mothers. There is no conclusive evidence that labor induced with pitocin or prostaglandin gel creates a risk in VBAC. However, some studies indicate that the use of prostaglandin gel in VBAC cases may increase the risk of uterine rupture, hemorrhaging, and hysterectomy in the mother and of subsequent fetal distress and infant death. Benefits Some of the benefits of VBAC are as follows: Epidural analgesia Fewer medical risks to mother and baby Less blood loss and fewer blood transfusions Less risk for infection for mother and infant Lower cost Shorter post-delivery recovery time for the mother

Prognosis The success rate for VBAC is approximately 6080% and can be higher if the patient had a vaginal delivery prior to c-section. In patients who had a c-section performed because of dystocia (abnormal or difficult labor), the success rate is lower. The most common causes of difficult labor include: Cephalopelvic disproportion or "CPD" (the infant is too large for the pelvis)

10 Reasons to Choose VBAC Vaginal Birth After Cesarean

By Robin Elise Weiss, LCCE, About.com Guide See More About: labor and birth epidural anesthesia drugs for labor natural childbirth doula
Sponsored Links

Having a C-Section?Don't Risk Your Baby's Life. Learn Why A C-Section Is Not Always Bestwww.C-SectionAdvice.com How To Get Pregnant FastI Stopped these common mistakes and got Pregnant almost immediately!www.PersonalPathtoPregnancy.net Orang Tua KandungSaya cari orang tua kandung saya Anda bisa membantu saya?where-to-look.blogspot.com Pregnancy Ads Pregnancy and Birth Pregnancy Website Birth Chart Birth Video Amp Storage VBAC or vaginal birth after cesarean doesn't need to be something to stress over. Many women are choosing to try a vaginal birth these days and the literature is very supportive of this decision. Most studies and facilities are finding that over 80% of mothers who have had a previous cesarean birth are safely and successfully having a vaginal birth with subsequent pregnancies. Here are some reasons that you may wish to consider a vaginal birth after cesarean (VBAC) or you might have some of your own to add!

VBAC is usually safer for mom and baby.

VBAC reduces the risks of infection to the mother. Labor is good for babies in most cases. Not having surgery makes mom's recovery easier. VBAC reduces the risks of respiratory problems in babies. VBAC involves a shorter hospital stay. More than 80% of women will be able to have a vaginal birth after a previous cesarean. Breastfeeding is easier after a vaginal birth. Usually for a variety of reasons, including faster and more direct access to your baby and less postpartum pain for mom. VBAC can help prevent injury to your internal organs, like your bladder, intestines, or even the need for an emergency hysterectomy. VBAC is less expensive.

Persalinan Pervaginam Pada Bekas Cesar dalam bahasa Inggerisnya Vaginal Birth After Caesarean Section (VBAC). Angka persalinan dengan Cesar yang wajar menurut WHO adalah 5-10 % dari seluruh kelahiran (Althabe and Belizan The Lancet 2006;368:1472-3). Ternyata diseluruh dunia angka bedah cesar meningkat dengan pesat. Angkanya di Indonesia aku nggak tahu pasti. Data dari RS Fatmawati Jakarta tahun 2002 angka Cesar nya 29.9 % Sepertinya angka ini cukup menggambarkan keadaan Indonesia secara umum. Itu angka tahun 2002. Bagaimana sekarang ? Sepertimya nggak ada penurunan (yang berarti). Aku pernah membaca suatu survey angkanya masih segitu2 juga (lupa sumbernya). Di Amerika berikut ini alasan kenapa angkanya tetap tinggi: 1) Rendahnya usaha untuk meningkatkan kemampuan wanita melahirkan normal. 2) Akibat tindakan obstetri seperti induksi pada serviks yang belum matang 3) Tidak mau memberikan informed tentang pilihan persalinan misalnya pada bekas Cesar lalu dicesar lagi 4) Kurang ngerti unggulnya persalinan normal dan bahayanya cesar 5) Dokter takut dituntut pasien (main amannya aja, walaupun cesar sebetulnya lebih berisiko) 6) Adanya tanggungan asuransi, sehingga dengan mudah mau di cesar (coba bayar sendiri! mikir2 nya pasti banyak) 7) Permintaan sendiri untuk di cesar karena nggak tahan sakit(hubungan erat dg no 6 & 1) Sebetulnya pada bekas operasi dapat dilakukan persalinan pervaginam. Adapaun syaratnya : 1) Indikasi operasi sebelumnya bukan karena panggul sempit 2) Bayi nggak ada kelainan letak (letak kepala) 3) Janin Tunggal 4) Insisi non-klasik (belahan dirahim tidak boleh tegak lurus) 5) Penyembuhan luka operasinya baik (nggak pakai lama)

6) Berat bayi nggak boleh lebih 4 kg Proses persalinannya disebut : TRIAL OF SCAR = Nyoba Jaringan Parut. Dimana proses mengedannya saat buka-an lengkap hanya boleh 2x 15 menit. Kalau nggak lahir juga harus dibantu dengan Vakum atau Forseps. Perlu diingat disini bahwa persalinan pervaginam adalah the best dari segi manapun. (ibu dan bayi, cost, risk) Berapa lama jarak yang aman antara satu persalinan dengan berikutnya? Tidak ada ketentuan di textbook. POGI sepakat jaraknya minimal 2 tahun baru boleh hamil lagi. Bagaimana jika sudah hamil lagi sebelum 2 tahun (kebobolan kb)...lanjutkan, nggak masalah. Nah satu lagi yang mungkin nggak diketahui orang awam, jangan dikira melahirkan kepala pada cesar gampang, apalagi pada bekas cesar sering dijumpai perlengketan. Kadang pada proses cesar dibutuhkan forseps atau vakum untuk mengeluarkan kepala. Seakarang tren-nya malah inisisi seminimal mungkin lalu bayi dilahirkan dengan forceps. Luka operasi yang nggak terlalu lebar akan mempercepat proses penyembuhan operasi. Berapa sih sebetulnya lebar luka sayatan dikulit? Penelitian di amerika rata-rata 14 cm. Dengan melahirkan bayi pakai forseps maka sayatan kulit bisa lebih kecil dari 14 cm. Nah sekarang coba periksa berapa panjangnya sayatan kulit masing....

Is Vaginal Birth Safe After C-Section? Risks From Labor After Prior Cesarean Delivery Low, Study Reports
By Tracee Cornforth, About.com Guide Updated December 18, 2004 About.com Health's Disease and Condition content is reviewed by the Medical Review Board See More About: pregnancy vbac risks post partum Press Release December 14, 2004

The risks from vaginal delivery after a prior Cesarean delivery are low, but are slightly higher than for a repeat Cesarean delivery. This finding is from the largest, most comprehensive study of its kind ever conducted, undertaken by the National Institute of Child Health and Human Development of the National Institutes of Health. The study appears in the December 16 New England Journal of Medicine. "These findings provide women who have had a Cesarean delivery and their physicians with reliable information to take into account when deciding whether to undergo labor or to have a repeat Cesarean delivery," said Duane Alexander, M.D., Director of the NICHD. Among the complications the study found in women who attempted a vaginal birth after prior Cesarean delivery were rupture of the uterus, infection of the uterine lining, lack of oxygen to the infant brain, and infant death. The study authors noted, however, that the risks of these complications were very low. Cesarean delivery consists of delivering a baby through an incision made in the abdominal wall and through the uterus, rather than through the vagina. Reasons for Cesarean delivery include failure of labor to proceed normally, fetal heart rate abnormalities, and complications involving the placenta. Because cesarean delivery is a major surgical procedure, it carries the risks posed by any other major surgery, such as infection or complications from the anesthetic. Having a Cesarean delivery may also complicate future births. Uterine rupture is the most well known complication of attempted vaginal delivery after a prior Cesarean delivery. Uterine rupture occurs when the scar in the uterine muscle opens. The rupture may result in part or all of the baby and perhaps the placenta leaving the uterus, which may cause fetal heart rate abnormalities and perhaps fetal death. A more severe, or catastrophic, rupture may result in heavy bleeding, which can endanger the lives of both mother and baby. In some cases, the bleeding may be so severe that a hysterectomy must be performed. However, repeat Cesarean delivery also may carry risks beyond those posed by delivering vaginally after a prior cesarean delivery, explained the NICHD author of the study, Catherine Spong, M.D., Chief of the Institute's Pregnancy and Perinatology Branch. The risk for infection and other surgical complications appear to be greater in women undergoing repeat cesarean delivery compared to those who are successful with a vaginal birth after Cesarean delivery.

Moreover, having a repeat cesarean delivery may complicate future pregnancies, sometimes causing the placenta to implant over the cervix, thereby interfering with the birth process. Prior Cesarean also increases the chances that the placenta will grow into the uterine wall, leading to difficulty with removal of the placenta after the birth. This may result in heavy bleeding during birth, perhaps leading to surgical removal of the uterus. The decision of whether to attempt a vaginal delivery or to have a repeat Cesarean must be made carefully by women and their physicians. They must take into account, on the one hand, the risk of uterine rupture and its attendant complications, and balance these factors against the risk of surgical complications and the chances that repeat Cesarean delivery might complicate future pregnancies. Citing figures compiled by the National Center for Health Statistics (NCHS), the study authors noted that the rate of Cesarean delivery had increased from 5 percent in 1970 to an all time high of 26 percent in 2002. Recent preliminary data released by the NCHS indicated an overall Cesarean delivery rate exceeding 27 percent for 2003. For the same period, the rate of vaginal birth after Cesarean delivery had fallen from 31 percent in 1998 to 10.6 percent in 2003. The U.S. Public Health Service, in its Healthy People 2010 Report, proposed a target rate of vaginal birth after Cesarean delivery of 37 percent. The NICHD Maternal-Fetal Medicine Units Network researchers undertook the current study to more precisely estimate the risks from vaginal birth after Cesarean delivery as compared to having a repeat Cesarean delivery. Before the current study, the only information on this topic was from studies that reviewed discharge codes from hospital records, Dr. Spong said. Such analyses, undertaken after the fact, may fail to include important information about the birth. Moreover, the few studies that had been conducted generally didn't include a large enough number of women for a reliable calculation of the risks involved. n 1994 the position of Caesarean Birth/VBAC co-ordinator for the NCT became vacant and we decided to take the post jointly, along with a third colleague. One of our major tasks has been writing a new NCT booklet entitled Caesarean Birth - Your questions answered which was published by the National Childbirth Trust in October last year. This booklet, which includes research evidence, practical tips and parents' experiences, will be helpful for many pregnant women and their partners.

A lively discussion followed our brief introduction and it quickly became obvious that the main area where information was lacking was that of caesarean scar rupture. Many questions were raised on this topic and since we were asked if we would submit an article to Midwifery Matters it was an obvious choice. Scar Rupture - Every Midwife's Nightmare The belief that vaginal birth after caesarean (VBAC) is dangerous owing to the risk of scar rupture is common, both among the general public and among those working in the maternity professions. Indeed an article in a national newspaper quoted the response of one obstetrician to a woman's request for VBAC was: 'That's alright Pam. Everyone has the right to die in the way they choose but I just don't want to be around at the time, and I'd rather it didn't take place in my hospital.' Not surprisingly the mother opted for an elective repeat section (The Times, 1996). Sadly, this is not an isolated incident. It is common. Women are told they will die, their baby will die, or they will require hysterectomy when, rather than if, their caesarean scar ruptures during a VBAC. We want to take a closer look at these possible outcomes. Incidence of Scar Rupture The most commonly quoted scar rupture for LSCS, especially by those opposed to and afraid of VBAC is 0.5%, or one in 200 (Murray, Enkin and Chalmers, 1994). We have been unable to obtain statistics concerning scar rupture in this country, but if one in every 200 VBAC labours had such serious consequences for the mother or baby, surely we would all be hearing about individual cases? There are no statistics generally available concerning the numbers of VBAC labours in Britain. Although VBAC studies show 'successful vaginal delivery' rates of around 80% can be achieved, actual hospital statistics for VBAC labours are generally considerably lower since a great many mothers are not given the opportunity and necessary support and encouragement to labour. Even so, substantial numbers of VBAC labours take place in this country every year and most midwives will not encounter a scar rupture during their career.

There are other severe problems that can arise during labour in all women. These include:

Placental abruption 1:100 cord prolapse 1:100 placenta praevia 1:200 (Flamm, 1990)

All pregnancies carry risks. However, although VBAC mothers maybe at a very small additional risk it seems invidious to single out the risk of scar rupture for special attention. We are not suggesting for one moment that scar rupture should not be mentioned, but information needs to be given out in a balanced way which does not disempower women or midwives. The scar rupture rate of 0.5% includes even slight dehiscences or 'windows' which carry no adverse sequelae. However, what mothers often understand by this much quoted statistic is that they have a one in 200 chance of losing their baby, their uterus or even their own life. Risk of Fetal Mortality On rare occasions babies do die as a result of caesarean scar rupture. However, as we have seen from the statistics, it is a rare event and the risk is nowhere near the 0.5% that is so often implied. The International Childbirth Education Association (JCEA) published a review, 'Vaginal birth after caesarean' in August 1990 (Sufrin-Disler, 1990). It reviewed current medical and scientific literature concerning VBAC and concluded: In over 21,000 planned labors after cesarean, five babies were reported to have died in association with scar rupture (0.02%). These figures include VBAC research from around the world. If only data from industrialised countries are considered, in over 17,000 planned labors after cesarean two babies have died in association with scar rupture(0.01%). In a review of the medical journals during the 35-year period 1950-1985, Bruce Flamm found reports of two fetal deaths per 10,000 (0.02%)

owing to low transverse uterine rupture (Flamm, 1990). Since the most recent and lowest perinatal mortality rate for England and Wales is 6.1 per thousand, VBAC mothers are not at a significantly higher risk of losing a baby than any other women. A mother is therefore 30 times more likely to lose her baby from some other cause. Despite evidence to the contrary, mothers continue to receive the impression that every scar rupture ends in the death of the baby, and that one in 200 VBAC babies dies from this cause. Risk of Hysterectomy Quoting from the same ICEA review concerning the risk of hysterectomy: Twelve mothers lost their uterus due to scar rupture during these 21,000 planned labors after cesarean (0.06%). This is less than one tenth of the 0.7% hysterectomy rate reported for 'obstetric hemorrhage' after cesarean section (Clark et al, 1984). Thus mothers who opt for a repeat section have a greater risk of losing their uterus. Risk of Maternal Mortality Regarding maternal mortality, the ICEA VBAC Review concludes: There has been no report of a mother who has died due to rupture of a cesarean scar during planned labor after cesarean. In contrast, reports continue to document deaths of women due to complications of elective repeat cesarean operations. Therefore it is unreasonable that mothers should continue to be threatened with this risk. Despite the wealth of evidence showing that serious wound dehiscence is a rare complication during labour after previous caesarean section, the safety of VBAC continues to be called into question and mothers continue to opt for elective repeat section in

the mistaken belief that this is safer than the risk of labouring with a scarred uterus (Murray, Enkin and Chalmers, 1994). But What If... Having established that the risks of scar rupture are low, and in most cases lower, than the risks of elective repeat caesarean section, we must nonetheless acknowledge that scar ruptures do occasionally occur with tragic results. When a baby dies the statistics are totally irrelevant to the mother. It doesn't matter to her (or the midwife concerned) whether she is one in 200 or one in two billion. There are no available British statistics on serious scar rupture. We don't know how many there are; their whereabouts or their circumstances. We don't know why scars rupture. In the rare instance that a true rupture of a caesarean scar does occur with serious consequences, the general reaction tends to be dismissive, a shrugging of shoulders and an acceptance that this is the risk taken with VBAC. There seems to be secrecy surrounding cases of scar rupture. Often this is explained away by patient confidentiality, possibly because it is such a rare occurrence that everyone would know who was being discussed. However, confidentiality should not mean concealing valuable information and preventing discussion of the circumstances. Without this openness we will continue to be unsure about any warning signs and be less able to take steps to reduce the risks of serious consequences in any future cases. Despite the lack of literature on the subject of poor outcome following caesarean scar rupture, a picture is beginning to emerge. Following an article published by The Association for Improvements in the Maternity Services (AIMS) we have been able to formulate what we think of as a recipe for a scar rupture disaster. Recipe for Disaster

Previous caesarean scar Induction with prostaglandin gel Augmentation Inexperienced and/or overloaded midwife Delay in recognising signs of scar rupture Delayed medical response

Although we have a list of ingredients, we have no quantities. However, we feel that a detailed discussion around the lack of knowledge in itself, can give those of us with a deeper understanding of normal birth a measure of confidence and much optimism since we do not believe that normal, healthy, naturally labouring women are at risk of scar rupture. Each ingredient of the recipe can provide a detailed area for discussion. Previous Caesarean Scar When a rupture takes place in a woman who has had a previous caesarean can we always be sure that it is the caesarean scar itself which has ruptured? It may be that on occasion this is simply assumed. It has been noted in the literature that often it is not possible to see a caesarean scar on the uterus with the naked eye (Francome and Savage, 1993). There needs to be clear differentiation between caesarean scar rupture and rupture of non-scarred uterine tissue. Clear, detailed information needs to be available on all ruptures. Issues such as rate of recovery from the caesarean, whether there was infection, the type of infection and how well it responded to treatment are among the areas where information is not collated and therefore cannot be connected to VBAC outcomes. Induction We understand that prostaglandin gel pessaries have only been in common use since the 1980s. Therefore most of the scar rupture statistics predate their use. It has become obvious to us that some obstetricians are aware of the possible dangers of using prostaglandin gel on women with scarred uteri. Others do not appear to know that while prostaglandins induce labour by dissolving the collagen network at the unripe cervix, they may also dissolve any collagen scar tissue at the site of a previous section thus leading to rupture (Kelly, 1996). Prostaglandins, once administered, cannot be controlled. More details are needed about the type, quantity, timings and physiological responses in order to know when they can be used with relative safety. Augmentation

Following prostaglandin induction it is common practice to augment labour with an oxytocin drip. Again details are need on timings, rate of administration and physiological responses. Older literature does question the use of oxytocin in women with scarred uteri, but this generally relates to studies performed before the advent of current technology which allows oxytocin to be administered in a very controlled way. Since oxytocin is known to have a short half-life, it may be possible to forestall a problem by simply turning off the drip. However, the safety of using both prostaglandin pessaries and oxytocin is still open to question. Inexperienced and/or overloaded midwife We know that midwifery staffing levels are sometimes well below optimum. It is considered normal practice for a midwife to be caring for more than one woman on a labour ward and her level of experience should always be taken into account. Subtle messages may be given out by labouring women and there may also be other indications that all may not be quite normal; these may not be picked up even by an experienced midwife who is overloaded, or may not be noticed until it is too late. In order for midwives to give optimal levels of care and ensure safety for all labouring mothers, we need a system where one midwife cares solely for one labouring mother whom she knows well. (Just what the One Mother, One Midwife campaign is currently calling to be made available for every mother who want it.) Women labouring at home are generally aware that they must take responsibility for their own safety. However, often when a woman labours in hospital she has handed that responsibility over. Therefore a woman labouring with minimal attention labours under a false sense of security. Delayed Medical Response We suspect that in serious cases of rupture the earliest signs will often have been missed. It is important that such signs are discussed with the benefit of hindsight so that other midwives and other mothers can learn about them. From our discussions with a very small number of women who have suffered a rupture, there seem to have been warning signs, including a

feeling of unease and even distress in the mother. The authors find it difficult to believe that a woman who is in touch with her instincts will be totally unaware of such a major impending event within her body. The mother may not of course accord any importance to such feelings at the time, and indeed medical staff may reassure her too effectively, leaving the warning signs ignored. If this is happening, we all need to be aware of it. We know of one case where a mother booked for a home VBAC transferred into hospital purely on instinct. During the ensuing emergency caesarean section for genuine fetal distress a rupture occurred up the rear uterine wall. The baby was fine and the uterus repaired. In other cases when early warning signs were missed and mothers falsely reassured the outcome was not so good. We are also aware that on occasions a midwife may have felt something was not right but had difficulty getting a doctor to take her seriously. Finally, when a rupture occurs we need to know what led to the diagnosis, by whom it was made, what actions were taken, how quickly, and the outcome. Conclusion It is not known how quickly a rupture must be dealt with in order to minimise the risks to mother and baby, and how much variation there may be in this. When a baby dies, any avoidable delays in getting the mother to the theatre may be relevant. It is not enough simply to accept the occasional fetal death owed to rupture as inevitable. It is likely that there will be reasons that can account for scar rupture and poor outcome. Admittedly, the foregoing discussion is unlikely to bring much peace of mind to those midwives who find themselves taking care of several women, all of whom are well on the road to a technological birth. However, we hope this article will give heart to those endeavouring to practise true midwifery. One of the criticisms often levelled at maternity professionals is that they do not see the long-term consequences of their actions and of various forms of care, especially caesarean section. Neither do midwives and doctors see the long-term benefits that excellent

midwifery can have for the mother, baby and the whole family. A good birth experience can have a wonderfully positive effect upon a woman's everyday life, her relationships with her baby, her family and others, her personal level of confidence, and her ability to cope with the trials of life in general. Few mothers realise how good midwifery care can optimise their birth experience, and even fewer know about the far reaching effects this will have on their future life. If and when they do, they are usually no longer in contact with the midwife and cannot express their gratitude. On behalf of all VBAC mothers now and in the future, 'Thank you'. We need midwives who will be 'with women' and all your efforts, no matter how small and inadequate they may seem to you, are very much welcomed, needed and appreciated by mothers, especially those who want a VBAC. Debbie Chippington-Derrick and Gina Lowdon
What is VBAC?
VBAC (pronounced veeback) stands for vaginal birth after caesarean section. It's the term used when you give birth vaginally, having had at least one baby born by caesarean section.

How does a VBAC differ from normal childbirth?

Advertisement

The main difference is how often and how closely your labour will be checked. You'll be offered continuous electronic fetal monitoring. This is to allow your baby's heart rate and your contractions to be measured at all times. Many women have a successful VBAC without any complications at all. But there is a very small risk that the scar from your previous caesarean could tear. This is called uterine rupture. Rupture affects only one in 200 women trying for a VBAC. Although the risk is small, your medical team will want to watch out for it. If your baby's heart rate doesn't sound right, it could be an early sign that there is a problem with your scar. During a VBAC you can have an epidural for pain relief if you want one. Some hospitals may support you using a birth pool to help you cope with your contractions. This will depend on why you had a caesarean last time. Your doctor will want to know how your last pregancies went, because if you use a pool your baby can't be monitored all the time.

What's the alternative to a VBAC?

The other option when you've had a caesarean is to have a planned repeat caesarean. This is usually booked for the seven days leading up to your due date, unless your baby needs to be born sooner for a medical reason. Overall, repeat caesareans and VBAC are both safe ways for you to have your baby.

You'll have plenty of time to mull over the risks and benefits of both options. Talk to your obstetrician about your previous birth or births. This will help you come to a decision about how to have your baby this time around. You'll be encouraged to decide by the time you are 36 weeks pregnant.

What are the advantages of a VBAC?

The main advantage is that you have a vaginal birth and avoid the risks of caesarean birth. You'll have much less pain after the birth and a shorter stay in hospital. Your baby is also slightly less likely to have trouble breathing after he's born, although few babies have this problem. If you felt disappointed that your last baby was born by caesarean, you may have a sense of achievement if you have your next baby vaginally. And once you've had one successful VBAC, you're more likely to have another one.

What are the disadvantages of a VBAC?

The disadvantages of VBAC are generally the same as with any vaginal birth:

Pain in the area between your vagina and back passage, or perineal pain, and stitches.

Leaking of urine in the first three months after birth.

In later years your uterus (womb) may slip down through your vaginal wall. This is called a prolapsed uterus, and is more likely to happen after the menopause. Prolapse affects only five per cent of mums. But it is nearly twice as likely to happen to mums who have had a vaginal birth. Make your pelvic floor exercises a lifetime habit to guard against this.

Trying for a VBAC, instead of choosing a caesarean, carries a slightly higher risk that something may go wrong. The chances of this happening, though, are very small. They include: needing a blood transfusion infection in your uterus after the birth in rare cases, rupture of the uterus

What else do I need to be aware of?

All labours are unpredictable. So there's always the chance that you might have to give up on your VBAC. A quarter of women who try for a vaginal birth then need an emergency caesarean. This usually happens because labour has slowed right down, or there are worries about the baby's wellbeing. But bear in mind that a woman trying for a VBAC is only slightly more likely to need a caesarean than a firsttime mum in labour.

Take time to explore your feelings about the birth. Do you feel that you cannot face a failed VBAC attempt? Or do you feel that you should at least give it a go? It's a highly individual decision. It can be difficult to decide, so talk it over with your midwife and doctor and your loved ones.

What are my chances of achieving a VBAC?

Your chances of having your baby vaginally are likely to be good. But it does depend on why you needed a caesareanbefore. It also depends on how your pregnancy is going this time around. If you needed a caesarean for a reason that won't change, such as a small pelvis, then you may need to have a caesarean again. However, if you had a caesarean because of something unique to your last pregnancy, such as abreech baby or a low-lying placenta, you stand a good chance of having a VBAC. It may help you to look at the numbers. Your chance of a successful VBAC is:

Between 87 per cent and 90 per cent if you've given birth to at least one baby vaginally in the past, particularly if it was a VBAC.

Between 72 per cent and 76 per cent if you've had one previous caesarean.

Between 70 per cent and 75 per cent if you've had two previous caesareans. This is very similar to the rates for vaginal birth for first-time mums. Read what our expert has to say about having a VBAC after several caesareans.

VBAC success rates are lower if you: Have your labour induced, particularly with prostaglandins. These are hormone-like substances that help stimulate contractions. Induction puts a greater strain on your scar and makes uterine rupture two to three times more likely than if you went into labour naturally.

Have only ever given birth by caesarean.

Previously had a caesarean because your baby got stuck during labour.

Are obese, with a pre-pregnancy body mass index of more than 30.

If all four of these factors apply to you then your chance of achieving a VBAC is reduced to 40 per cent. A repeat caesarean may also be safer than a VBAC if you are expecting a big baby.

Can I have a VBAC at home?

A home birth is always an option if you are hoping to have a vaginal birth. However, you may find that your doctor and midwife are less keen to support you trying for a VBAC at home. This is mainly because of the small risk of uterine rupture. Having a VBAC at hospital means that if the worst happened, for example if your scar tears, you can be treated straight away. Ideally, a caesarean should be done within 30 minutes of an emergency arising. You could find out what the transfer time into hospital from your home would be to help you decide. If you want to have your baby at home it may be worth getting in touch with one of your local heads of midwifery. Your midwife can give you their names. A senior midwife can take you through all your options. She can also help you to plan the safest care for you and your baby. You could also employ an independent midwife, but you will have to pay for her services. Contact the Independent Midwives Association for a list of midwives in your area.

Key messages
Whether or not to have a VBAC can be a difficult decision. So here are the key points again:

If you wish to have a VBAC, your doctor should support your choice. However, you should also be fully informed about the pros and cons.

VBAC carries a small risk of uterine rupture.

If your doctor or midwife is unsupportive of your VBAC, contact your local head of midwifery to discuss your case, or consider using an independent midwife.

What is a VBAC?

Vaginal Birth After Cesarean is what VBAC stands for. It is a vaginal birth after one or more cesareans. More than 80% of women will be able to have a VBAC. According to Midwifery Today (most recent issue, Winter No 36 page 47) ACOG recently updated their opinion on VBAC and stated "VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk". The Guidelines can be obtained from: ACOG, 409 12th St SW, Washington DC 20024.
Why would I want a vaginal birth?

There are many reasons that you may want a vaginal birth after a cesarean. Some may be medical and some may be emotional. Others may be financial or in terms of recovery. Here are some brief lists of the benefits to the mother and baby of a vaginal birth.

Mother: Prevention of Death from surgery Prevention of lesser complications from surgery Prevention of blood loss Prevention of infection Prevention of injury (bowel, urinary tract, etc.) Prevention of blood clots in the legs Prevention of feelings of guilt or inadequacy that surgery sometimes causes Breastfeeding is generally easier after a vaginal birth The cost of a vaginal birth is about $3,000 less Baby:

Prevention of Iatrogenic Prematurity (meaning surgery was done, because of an error in guessing a due date) Reduction in the cases of Persistent Pulmonary Hypertension Labor prepares the baby for extrauterine life Prevention of surgery related fetal injuries (lacerations, broken bones) VBAC results in fewer fetal deaths than elective repeat cesareans

What about rupture of the uterus?

This is a common fear among women who have had a previous cesarean. Most of this fear dates back to when the incisions of the original cesarean were of the classical variety (vertical incisions), nowadays most incisions are the low transverse type. There are two types of uterine rupture: complete and incomplete. Complete uterine rupture is very unlikely today, for a variety of reasons. One is that when we use Pitocin, if needed, during a labor, we regulate the amount that goes in. In other times it was given IV to a woman and allowed to flow freely. These have also decreased due to some obstetrical practices being abandoned, like high forceps, internal version, etc. And the final reason is because of the rarity of the classical incision. A complete rupture occurs in much less than 1% of women attempting VBAC.

Incomplete rupture occurs about 1-2% of the time. However, usually these women are asymptomatic, and neither mother or infant require any assistance. Golan published a study in 1980, where there were 93 ruptures of the uterus. 61 of those ruptures occurred in a normal uterus (never had an incision), and 32 of them had had previous incisions. There were 9 maternal deaths from the ruptures, but they were all from the group that had not had previous cesareans. For more information, see Studies on VBAC.
Pregnancy After Cesarean Section

You may be worried to be pregnant again, and really don't know where to turn for information or support. You may wonder what you can do to increase your chances of a successful VBAC. There are several things you can do, they are listed below in Preparing for your VBAC. Basically, the same rules of pregnancy apply, eat well, exercise, educate yourself, and develop a good birth team. Take responsibility for your care.
Labor After a Cesarean

The time has come. Labor has arrived! What will it hold for you? Many women are very emotional about the labor, and rightly so. Critical times may be the place where you got "stuck" at the last birth, when your water breaks, getting to the hospital, or any other time. Support is critical, turn to those around you. Here are some questions that many women have about laboring with a VBAC. What if I had a cesarean because my pelvic bones were too small? Most women do not truly have pelvic bones that are too small, unless you have suffered a pelvic fracture or had polio. Women with a pelvis to small to give birth vaginally are truly few and far between. Many women go ahead to deliver vaginally the next time, and have a bigger baby than the first! What if the baby is large? The pelvis and the baby's head are not rigid structures. Both mold and change shape to allow the birth to occur. There are certain postures that you can assume to help your pelvis expand (For example: Squatting opens the outlet of the pelvis by 10%.) The American College of OB/GYNs (ACOG) has stated that the effects of labor with a baby of

more than 4,000 grams (8 3/4 lbs) has not been substantiated. However, in one study, 67% of babies weighing more than 4,000 grams were born vaginally, even when over 50% of these mothers had had previous cesareans for failure to progress. What if I have had Herpes? In years past, many women were delivered by cesarean for a history of genital herpes. Doctors did cultures in the last weeks of pregnancy to determine if the infection was active. ACOG has determined and recommended that unless there is a visible lesion at the time of birth, a vaginal birth is acceptable. What if I have had more than one cesarean? From the Guide to Effective Care in Pregnancy and Childbirth: "The available data on outcomes after a trial of labour in women who have had more than one previous caesarean section show that the overall vaginal delivery rate is little different from that seen in women who have had only one previous caesarean section."... and also ... "the available evidence does not suggest that a woman who has had more than one previous ceasarean section should be treated any differently for the woman who has had only one caesarean section". What if the other cesarean was for fetal distress? True fetal distress is rare, and only a handful of cesareans are done for fetal distress. One study indicates that fetal distress only occurs in 1.5% of all VBAC attempts (Finley, Gibbs), while another showed that of mothers who had a primary cesarean for fetal distress, the second labor had 3% of those mothers with fetal distress (Paul, Phelan, Yeh). This brings us to fetal monitoring. In a normal, low risk pregnancy, fetal monitoring has not been shown to improve maternal or fetal outcomes, rather it only serves to increase the cesarean rates. Some care providers insist on continuous electronic fetal monitoring for VBAC clients. This is something that you need to research beforehand, and decide if it is something you want and can live with.
Specifications for VBAC

Who is a candidate for VBAC? The general guidelines for VBAC are:

Low transverse incisions on both the abdomen and uterus Adequate pelvis (See Above) Willingness to prepare for VBAC

Preparing for your VBAC

There are many things that you should do to prepare yourself for a VBAC. Some are mental, emotional, physical and general preparations for your VBAC. Information. Get as much of it as you can. Obtain a copy of your medical records from the previous birth(s) for yourself. Ask your current careprovider to explain anything that you don't understand. Talk to your careprovider, make plans with them (See Birth Plan FAQ). Talk to other people who have been there. Read a lot of books and journals. Physically you need to prepare your body. Being in good physical condition can help your labor move more quickly as well as speed healing. Regular exercise and special birth exercises are good ways of doing this. For more information on how to prepare yourself, check out the VBAC Checklist
Birth Alternatives with VBAC

Can I use a midwife? You certainly can. As we have discussed before, with a few exceptions, VBAC is actually safer than an elective repeat cesarean. Midwives are trained to detect problems and can refer you to their back-up physician, should you need that type of care. Can I give birth at a birth center? Once again, this goes back to you and your careprovider. Can I still have a homebirth? This is up to you and your careprovider. Most practitioners of homebirth do not see any reason why you cannot have a homebirth VBAC. What about medications?

Medication is labor and birth is fairly controversial, even without VBAC. When you are talking pain relief medications, you need to think some things through. Unless you do not want them or have a medical reason for not having them, pain relief medications can be used with a VBAC. However, it is important to use them wisely. We know that epiduralscan increase the cesarean rate. You may want to consider delaying medications and using non-pharmacological methods of pain relief as long as you possibly can. Some studies indicate that if you delay an epidural past 5 cms then you lose the risk of increased cesarean. Narcotics are also sometimes used in labor. While these do not have a direct effect on your chances of cesarean, they do have an effect on your mobility and your mind. Some women feel that their minds were clouded when they used narcotics. Often, once you receive a narcotic you are confined to bed, limiting your mobility, which can hinder labor. There are also effects of these drugs on babies that are much more apparent. Pitocin, used to induce or speed labor, was once controversial in VBAC births. However, in the American College of OB/GYNs VBAC Guidelines it states that pitocin is safe for use with VBAC births, because the risks of uterine rupture is so small. Vaginal Birth After Cesarean (VBAC) Billings MT
There are pros and cons to both repeat c/sections and an attempt at vaginal delivery, so patients should be well-versedon both so that they can make an informed decision regarding their health care. While an attempt at vaginal deliverafter a low-transverse c/section is usually quite safe, current medical standards clearly show that women who havehad a classical c/section should not undergo an attempt at vaginal delivery, since the chance of uterine ruptureis too high to risk. Vaginal Birth After Cesarean (VBAC) by D. Ashley Hill, MD, OBGYN.net Editorial Advisor, Associate Director - Department of Obstetrics and Gynecology, Florida Hospital Family Practice Residency, Orlando, Florida About 25% of all babies in the United States are born by cesarean delivery, creating a situation where many women have to choose whether or not to have a repeat c/section, or to undergo an attempt at vaginal delivery for their next pregnancy. In medical terminology this is called a "vaginal birth after cesarean," or VBAC, and is pronounced "V-BACK." Scientific investigation has led to considerable information about this process, and by reviewing this information, and discussing this issue with a physician or midwife, patients can determine if they wish to have another c/section or to try for a vaginal delivery. VBAC's are successful on average 60-80% of the time and are considered by most to be a valid way to reduce the overall c/section rate. Before discussing the pros and cons of either a repeat c/section or an attempt at vaginal delivery, it is helpful to discuss what occurs during a c/section. Basically, an Ob/Gyn doctor makes an incision into the skin of the abdomen, usually via a "bikini cut" but sometimes via an

up-and-down cut called a vertical skin incision. He or she then cuts through each layer of tissue until reaching the uterus, which is essentially a large muscle. The area closest to the bladder, called the "lower uterine segment," heals better than the upper part of the uterus, so doctors make an incision in this lower area 90% of the time. The doctor makes a sideways cut, (going the same direction as the bikini cut), into this area, then reaches in, cups the baby in her or his hand, and delivers the baby through the incision. This sideways cut on the uterus is called a low transverse c/section, or LTCS for short. The uterine incision is sutured closed and heals over the next 2-6 weeks. In unusual cases the doctor may need to make an up-and-down (vertical) cut into the muscle of the uterus, which is called a "classical c/section" to deliver the baby. Since this cut is through muscle, it may not heal well, and can come apart during the next pregnancy or delivery. This is called a scar breakdown, scar dehiscence, or a uterine rupture, depending on the extent of breakdown. When this happens the baby, umbilical cord, or placenta (afterbirth) may pop through the opening in the uterine muscle and into the abdominal cavity, causing bleeding, fetal distress, and, in some cases, even brain damage or death. If the uterus actually ruptures (which is thankfully rare), the mother can hemorrhage, leading to an emergency hysterectomy. This is much more common with classical c/sections than low transverse c/sections. As frightening as this sounds, we know through medical research that uterine scar breakdowns (and especially uterine ruptures) are relatively uncommon events, occuring in 5-12% of classical incisions and 1/2 of 1% of low-transverse incisions. There are pros and cons to both repeat c/sections and an attempt at vaginal delivery, so patients should be well-versed on both so that they can make an informed decision regarding their health care. While an attempt at vaginal deliver after a low-transverse c/section is usually quite safe, current medical standards clearly show that women who have had a classical c/section should *not* undergo an attempt at vaginal delivery, since the chance of uterine rupture is too high to risk. These women should undergo a repeat c/section for every subsequent pregnancy. Therefore, this paper will focus on women who have had a low transverse c/section, since they may safely undergo an attempt at vaginal delivery if they wish. Please note that the important incision is on the uterus, and that the type of *skin* incision is irrelevant. There are many benefits of vaginal delivery, for both mother and baby. During a vaginal delivery the amniotic fluid is squeezed from the baby's lungs, making it easier for him or her to breathe. This does not happen as much during c/section. Furthermore, it is a misconception that c/section is always safer for babies than vaginal delivery. Scalpel injuries and trauma to babies during c/section, although rare, can certainly occur. In most cases vaginal deliveries are safer for mothers than c/sections, with some medical studies indicating that the chance of death for a mother is 7 times higher when delivered by c/section versus vaginally. Contrary to popular belief, a c/section is a *major* operation, not unlike a hysterectomy in it's complexity and potential complications! These complications may include infection, hemorrhage, scar tissue formation (which may produce lifelong abdominal or pelvic pain), anesthesia complications, opening of the skin incision leading to a very large scar, damage to the bladder or intestines, and the formation of blood clots within blood vessels or the lungs. These complications are usually much more common with c/sections than vaginal deliveries, although as with all medical issues the patient's individual situation will dictate which complications are more, or less, likely. An unfortunate side effect of our legal system is that many women are led to believe by malpractice lawyers that a c/section will prevent any and all problems for their baby. This is simply untrue and is a very unsophisticated way of

looking at this major operation and pregnancy in general. There are certain risks that are more likely when a patient has had a prior c/section. These include scar tissue formation around the uterus that may make another c/section technically difficult, and the development of placenta accreta, where the placenta grows into the prior uterine scar, sometimes leading to hemorrhage and emergency hysterectomy. The most uncommon, but most significant, risk is uterine rupture. This occurs in about 1/2 of 1 percent (about 0.5%) of patients who have had a prior low-transverse c/section. As discussed, this may result in hemorrhage or harm to the baby, but both of these are actually uncommon. Uterine ruptures usually cause significant pain, so close observation by a patient's doctor and nurse, and perhaps the use of fetal monitoring, will often diagnose this condition. Since we know that vaginal deliveries are almost always safer for the mother, and usually as safe for the baby, and that VBAC attempts are successful in about 80% of cases, why do some women still choose to have a repeat c/section rather than try for a vaginal delivery? In some cases it is fear of pain during labor (although many patients report that the pain from recuperation from a c/section is worse than labor pain), in others it is a "fear of the unknown," while for some women there is a convenience in scheduling the exact date of their baby's birth. Some patients desire a tubal ligation and believe that it is safer to undergo a c/section and tubal ligation rather than a vaginal delivery with subsequent tubal ligation, although medical research has shown this to be untrue. Finally, a number of women do not wish to take the risk, no matter how rare, of uterine rupture. No matter what the reason, since there is a small risk with an attempt at vaginal delivery and a risk with repeat c/section, patients should make the best choice for themselves, based on their specific medical history, doctor's advice, and individual situation.

Wikipedia

Vaginal birth after caesarean

From Wikipedia, the free encyclopedia

Vaginal birth after caesarean (VBAC) refers to the practice of delivering a baby vaginally (naturally) after a previous baby has been delivered through caesarean section (surgically).[1] . A caesarian section leaves a scar in the wall of the uterus. This scar is weaker than the normal uterine wall, so if the woman goes in labor in a subsequent pregnancy there is a higher than normal risk of a ruptured uterus. Because of this risk an attempt at normal vaginal delivery was for most of the 20th century considered unacceptably risky. This opinion was challenged by many studies showing that many women with previous caesaran sections did have successful vaginal deliveries. In the 1980s and 1990s there was a strong movement to encourage attempts at vaginal delivery after caesarean section. Mothers with a previous 'bikini cut' or lower uterine segment cesarian were considered the best candidates, as that part of the uterus does not contract during the birthing process. Nevertheless as there was yet no consensus on the management of such births, tactics such as induction of labour were still applied to VBAC candidates. In addition to that ultrasound was not consistently used to monitor the thinning of the

lower uterine segment during delivery. Induction led to an increase of uterine ruptures and lack of consistent ultrasound management of the uterine scar thickness led to women with very thin scars to take unacceptable risks. We know now that induction, especially using prostagladins causes chemical changes in the integrety of the uterine body, increasing the chances of adverse effects. In addition studies on the lower uterine segment thickness have shown that if the thickness at the 38th week of the pregnancy has reached a minimum of 4.5mm, which is the same of the unscarred uterus, then the chance of rupture is essentially non existent. Studies in the 1990s confirmed that vaginal delivery after previous caesaran section was riskier than average. The American College of Obstetrics and Gynecology issued subsequent guidelines which identified VBAC as a high-risk delivery requiring the availability of an anesthesiologist, an obstetrician, and an operating room on standby (Int J Gyn Obs; 1999; vol 66, p197). Nevertheless practices such as induction and lack of ultrasound management still continue In the 1990s the rate at which VBAC was tried fell from 26% to 13%. Many hospitals could not commit to the new guidlines and in addition a number of health insurance companies would not support it. Today only about 10% of eligible women in the United States try a VBAC According to the American Pregnancy Association, 90% of women who have undergone cesarean deliveries are candidates for VBAC.[2] From 60-80% of women opting for VBAC will successfully give birth vaginally.[2][3]
Contents
[hide]

1 Drawbacks and benefits 2 Eligibility 3 History 4 See also 5 References 6 External links

[edit]Drawbacks

and benefits

The decision to have a trial of VBAC is made by the mother with the advice of her obstetrician. The decision is guided by an assessment of the known risk factors for complications. In general, an attempt at VBAC is safe if there are no other identified risk factors affecting the mother or baby.

Risks of cesarean section include a higher chance of re-hospitalization after birth, infertility, uterine rupture in the next pregnancy, injury to the baby, premature birth and respiratory problems in the baby, as well as bonding and breastfeeding difficulties. [4] The risk of uterine rupture in a VBAC is 0.2% to 1.5%, being on the lower range in cases of lack of induction or any other intervention during childbirth
[2]

The risk of infection doubles if vaginal delivery is attempted but results in another cesarean. [2]. All complications of cesarean section are more likely and more severe if it is done as an emergency after a failed attempt at vaginal delivery rather than as a planned operation. [edit]Eligibility There are several common methods of determining eligibility. Some common factors include: [3] If the previous caesarean(s) involved a low transverse incision there is less risk of uterine rupture than if there was a low vertical incision, classical incision, T-shaped, inverted Tshaped, or J-shaped incision. A previous successful vaginal delivery (before or after the caesarean section) increases the chances of a successful VBAC. The reason for the previous caesarean section should not be present in the current pregnancy. The more caesarean sections that a woman has had, the less likely she will be eligible for VBAC. The presence of twins will decrease the likelihood of VBAC. Some doctors will still allow VBAC if the twins are positioned properly for birth. VBAC may be ruled out if there are other medical complications (such as diabetes), if the mother is over 40, if she is past her due date, if the baby is in the wrong position, etc. For women planning to have many children, VBAC may be a better option because repeat caesarean sections get increasingly complicated with each subsequent caesarean section.

[edit]History VBAC is not uncommon today. The medical practice until the late 1970s was "Once a caesarean, always a caesarean," but a consumer-driven movement supporting VBAC changed the standard medical practice. Rates of VBAC rose in the 80s and early 90s, however they have fallen since. What is VBAC? Vaginal Birth After Cesarean is what VBAC stands for. It is a vaginal birth after one or more cesareans. More than 80% of women will be able to have a VBAC. VBAC is safer than repeat cesarean and VBAC with more than one previous cesarean does not pose any increased risk. Tips for a Healthy Vaginal Birth Use these tips to help ensure your VBAC goes well. Get in training. Labor is the hardest work you'll ever do, but it's worth it! Focus on good nutrition and exercise Make a daily checklist to ensure you are getting essential nutrients Exercise daily: swim, walk, yoga, prenatal fitness class -- whatever feels good. Plus, being in good physical health will help make your labor easier and possibly shorten your healing time afterwards. Take prenatal classes. Be sure to register early for a VBAC, refresher or any other quality prenatal program. Even though you may have taken classes in a previous pregnancy, an evening out together with your partner will help to prepare you both, promote discussion, give you ideas on coping with labor and focus on this baby and its birth. Look for a supportive care provider. Find someone who believes in VBACs, has a VBAC success rate over 75% and a cesarean rate that is lower than the community average. If you are unsure about anything, get a second opinion. Get as much information as you can. Obtain a copy of your medical records from the previous birth(s) for yourself. Ask your current care provider to explain anything that you don't understand. Talk to your care provider, make plans with them. Talk to other people who have been there. Read a lot of books and journals. More VBAC Tips Establish a safe supportive birth environment to facilitate labor Try a variety of positions. Standing or walking instead of lying down facilitates labor while squatting to push can be more effective. Continue eating and drinking. Labor is hard work and takes a lot of energy. Far from eliminating the risk of aspiration with general anesthesia, total fasting may increase the risk by raising the acidity of the stomach contents. Fasting may also make it harder for the uterus to work. Learn to trust, cooperate with and listen to your body and your own unique labor pattern. Reassure family and friends. Remember that, according to medical studies, VBAC is usually safer for both you and your baby than a repeat cesarean. Attend VBAC support meetings or, if there are none in your area, join national organizations. Through meetings and newsletters you'll hear from others who've "been there" and will share their VBAC experiences.

Why Would I Want a VBAC? Every woman has a different reason for wanting a vaginal birth after a cesarean. For some, the justification may be medical and while other women feel an emotional need to give birth vaginally. For others still, the cause may be financial or in terms of recovery. There are numerous benefits of a vaginal birth. For mothers, these benefits include: etc.) Reduced risk of maternal death Fewer complications Prevention of blood loss, infection, blood clots in legs and injury (bowel, urinary tract,

Breastfeeding is generally easier after a vaginal birth The cost of a vaginal birth is about $3,000 less Your baby also benefits from a vaginal birth: Prevention of Iatrogenic Prematurity (meaning surgery was done because of an error in guessing a due date) Reduced chance of Persistent Pulmonary Hypertension Prevention of surgery related fetal injuries (lacerations, broken bones) VBAC results in fewer fetal deaths than elective repeat cesareans Risks of VBAC A common fear among women who have had a previous cesarean is rupturing of the uterus. Most of this fear dates back to when the incisions of the original cesarean were of the classical variety (vertical incisions). There are two types of uterine rupture: complete and incomplete. Complete uterine rupture is very unlikely today for a variety of reasons. First, if pitocin is used during labor, the amount is regulated. Previously, it was administered through IV to a woman and allowed to flow freely. Secondly, because of the rarity of vertical incisions, the number of ruptures has lowered. Nowadays, most incisions are the low transverse type, which means the incision is made across the lower part of the uterus. A complete rupture occurs in less than 1% of women attempting VBAC. Incomplete rupture occurs about 1-2% of the time. However, usually these women are asymptomatic, and neither mother nor infant require any assistance. Am I a Candidate for VBAC? Whether or not you will be able to try VBAC will depend on several things. These include: Low transverse incisions on both the abdomen and uterus from previous cesarean. If you had a low-transverse uterine incision, as 95 percent of women do today, your chances of having a VBAC are good. However, if you had a classic vertical incision down the middle of your uterus, you will probably not be allowed to attempt a vaginal delivery because of the possible risk of rupture of your uterus. Adequate pelvis Reason for previous cesarean. If the reason that you had the previous cesarean was something that is not likely to repeat during this pregnancy, such as infection, drug or alcohol abuse, preeclampsia etc., you are a good candidate for VBAC. If, however, the reason for your cesarean was a chronic illness that is likely to impact your current pregnancy, such as high blood pressure or diabetes, you will probably require a repeat cesarean. Willingness to prepare for VBAC

Vaginal Birth after Cesarean (VBAC) Billings MT

There are several reasons why a woman should want to attempt a vaginal delivery. First of all, there are more risks involved for the mother with a cesarean section, it is after all, major abdominal surgery. This means that there is more of a chance for blood loss, transfusion, and infection. There will be more days spent in the hospital after delivery, and the overall recovery time at home for the mother is much longer than the recovery from a vaginal delivery. In addition, the hospital costs can be more than twice as expensive. Bradley Goldberg, MD Almost 25% of the babies born in this country are delivered by cesarean section. Of these cesarean deliveries, one-third are repeat cesarean sections. In the past, it was believed that once a woman had a cesarean section, that all of her subsequent deliveries should also be cesarean. However, the current medical opinion is that most of these women can attempt a natural, vaginal delivery. There are several reasons why a woman should want to attempt a vaginal delivery. First of all, there are more risks involved for the mother with a cesarean section, it is after all, major abdominal surgery. This means that there is more of a chance for blood loss, transfusion, and infection. There will be more days spent in the hospital after delivery, and the overall recovery time at home for the mother is much longer than the recovery from a vaginal delivery. In addition, the hospital costs can be more than twice as expensive. For all of these reasons, women who have had a cesarean in the past should strongly consider natural delivery for subsequent pregnancies. Several studies support this recommendation, and successful vaginal deliveries are possible in up to 80% of appropriately selected patients. The 20-30% who are not successful will require a repeat cesarean section. As with most medical procedures, there are risks involved in attempting a vaginal birth after cesarean section (VBAC). For the most part, these risks are less than the risk of proceeding with an automatic repeat cesarean delivery. In fact, numerous medical studies have demonstrated that there is no increased risk of illness or death to the mother or the baby when VBAC is attempted. An important point here is that some women may not be a candidate for a trial of labor after a previous cesarean delivery. For the most part, whether or not you would be a candidate depends upon the type of incision made on your uterus (womb) during the previous cesarean section. This information is readily available to your doctor through hospital records. After obtaining these records, your doctor can discuss your options and any risks involved. Of course it is always your right as a patient to request the delivery route that you feel is most appropriate for you, and your baby.

The study, conducted in the tertiary care military hospital of Muscat, Sultanate of Oman, describes the outcome of vaginal birth after caesarian section (VBAC) in women with a previous caesarean. The women opted for trial of labor was subjected to obstetric protocol of the hospital. Of the 370 women on trial of scar, 74.86% had successful vaginal delivery and 25.14% had

emergency caesarean section. Majority (93%) had spontaneous onset of labor and it was induced in the rest with prostaglandin E2 vaginal gel. VBAC was higher in those with a prior vaginal birth and was poor among women operated upon earlier for failed progress of labour or cephalopelvic disproportion. But for one maternal death due to sickle cell crisis, no serious complications occurred for mother or the baby. To conclude, if women with previous single caesarean section for nonrecurring indication are subjected to trial of labor, around 75% could have successful vaginal delivery.