Vbac2010a

Trial of Labor After Previous Cesarean Delivery “TOLAC” The term trial of labor refers to a trial of labor in women who have had a previous cesarean delivery, regardless of the outcome. TOLAC MAY LEAD TO SUCCESFUL VBAC September 2010

ACOG # 115 2010 ,[object Object],[object Object],[object Object],[object Object],[object Object]

The American College of Obstetricians and Gynecologists guidelines for identifying women who are potential candidates for TOLAC NOW include the following: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Contraindications for VBAC ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Uterine Rupture By Incision Location ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

2 previous C /S C andidates but C ounsel C arefully ,[object Object],[object Object],[object Object],Obstet Gynecol 2006;108:12–20. Am J Obstet Gynecol2005;192:1223–8

2 PREVIOUS C/S ACOG 2010 ,[object Object],[object Object],[object Object]

Maternal Factors Associated VBAC SUCCESS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Maternal Factors Associated VBAC FAILURE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

TOLAC/VBAC SUCCESS COUNSELING CALCULATOR 2010 ACOG ,[object Object],[object Object],[object Object]

VAGINAL BIRTH AFTER CESAREAN Height & weight optional; enter them to automatically calculate BMI Maternal age Height (range 54-80 in.) Weight (range 80-310 lb.) Body mass index (BMI, range 15-75) African-American? Hispanic? Any previous vaginal delivery? Any vaginal delivery since last cesarean? Indication for prior cesarean of arrest of dilation or descent?

SAMPLE PATIENT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CONSIDER THE RESULTS Consider additional Information ,[object Object],[object Object]

ACOG/TOLAC CALCULATOR ACOG 2010 ,[object Object],[object Object],[object Object]

ACOG/TOLAC CALCULATOR ACOG 2010 ,[object Object],[object Object]

The MFMU Cesarean Registry: Prospective study with > 14,500 vbac attempts ,[object Object],[object Object],[object Object]

Success for VBAC by History ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Am J Obstet Gynecol 2005; 193:1016

Success for VBAC by history ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Increase BMI > 39 = Increased risk ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Obstet Gynecol. 2006 Jul;108(1):125-33 MFMU

VBAC Safety and Success AT OR Beyond 40 weeks of gestation ,[object Object],[object Object],[object Object],Obstet Gynecol. 2005 Oct;106(4):700-6

40 WEEKS OR GREATER ,[object Object],[object Object],[object Object],[object Object]

4000 GRAMS MACROSOMIA ,[object Object],[object Object]

TWINS ,[object Object],[object Object]

INDUCTION/AUGMENTATION ,[object Object],[object Object],[object Object],[object Object]

COUNSELING RISK OF UTERINE RUPTURE ,[object Object],[object Object],[object Object],Am J Obstet Gynecol 1999;181:882 N Engl J Med 2004;351:2581–9 N Engl J Med. 2001 Jul 5;345(1):3-8. ACOG Number 115, August 2010

IS THERE A role of UTERINE CLOSURE in the risk of uterine rupture NOT CONSISTENTLY DEMONSTARTED AS A RISK FACTOR AND NOT INCLUDED BY ACOG AS A RISK FACTOR ,[object Object],Bujold E Obstet Gynecol. 2010 Jul;116(1):43-50 Bujold E Am J Obstet Gynecol. 2002;186(6):1326-30

Controversy Regarding Closure of the Uterus ,[object Object],[object Object],[object Object]

Short Interdelivery Interval Time elapsed from previous delivery date to current TOLAC ,[object Object],Obstet Gynecol. 2010 May;115(5):1003-6 Obstet Gynecol. 2007 Nov;110(5):1075-82. Am J Obstet Gynecol. 2002 ;187(5):1199-202 Obstet Gynecol. 2001 Feb;97(2):175-7 Am J Obstet Gynecol 2000;183:1180–1183

If Uterine Rupture Occurs with Immediately Available Team ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Maternal Risks ERCD (%) TOLAC (%) One CD Two CDs Endometritis 1.5–2.1 2.9 3.1 Operative injury 0.42–.6 0.4 0.4 Blood transfusion 1–1.4 0.7–1.7 3.2 Hysterectomy 0–0.4 0.2–0.5 0.6 Uterine rupture 0.4–0.5 0.7–0.9 0.9–1.8 Maternal death 0.02–0.04 0.02 0 ACOG Number 115, August 2010

Neonatal risk ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Neonatal Risks ERCD (%) TOLAC (%) IUFD 37–38 weeks 0.08 0.38 IUFD 39 weeks or greater 0.01 0.16 HIE 0–013 0.08 Neonatal death 0.05 0.08 NS Perinatal death 0.01 0.13 HYPOXIA Neonatal admission 6.0 6.6 NS Respiratory morbidity 1–5 0.1–1.8 Transient tachypnea 6.2 3.5 Hyperbilirubinemia 5.8 2.2

DOCUMENTATION MANDATORY ,[object Object],[object Object],[object Object],[object Object]

Dr Montgomery Recommends ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Vbac2010a

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Vbac2010a