PROVIDER GUIDELINES FOR WORKING WITH PATIENTS  WHO MAY BE VBAC CANDIDATES OR WHO ARE CONSIDERING ELECTIVE REPEAT CESAREAN SECTIONS

 

In order to improve patient safety, provide excellent obstetrical care, and to decrease controversy concerning patient management, we have developed these guidelines to help the providers work with our patients who have had previous cesarean sections.

 

The following patients are candidates for TOL/VBAC¹:

1)    Patients with one low transverse cesarean section;

2)    Patients with two low transverse cesarean sections but have at least one vaginal birth;

3)    Patients with low vertical hysterotomy incisions are candidates if the hysterotomy incisions did not extend into the muscular portion of the uterus;

4)    Patients with unknown uterine scars but whose previous cesarean sections were done for clinical indications and/or in countries in which low transverse hysterotomies were most likely performed.

 

The following patients are NOT candidates for TOL/VBAC¹:

1)    Patients with one or more classical (vertical) cesarean hysterotomies;

2)    Patients with two low transverse cesarean sections and no vaginal births;

3)    Patients with one or more low vertical cesarean hysterotomies with extension of the hysterotomy incisions into the muscular portion of the uterus;

4)    Patients who have had low transverse cesarean sections, but the incisions were extended into the muscular portions of the uteruses (“T”, “J”, or “Hockey-stick” extensions);

5)    Patients who have had uterine fundal surgeries in which the full thicknesses of the myometrium were violated (i.e. extensive fibroid surgery, cornual pregnancy resection, etc.);

6)    Patients with previously ruptured uteruses;

7)    Patients with medical or obstetrical histories that preclude vaginal delivery.

 

What are the benefits of attempting a VBAC? The patient should be counseled that if successful:

1)    Her recovery time after the vaginal birth is shorter:

2)    She has avoided the risks of major abdominal surgery;

3)    She has a decreased risk of infection after delivery;

4)    She has a decreased risk of blood transfusion;

5)     She has been able to experience a more natural birthing process.

 

What are the disadvantages / risks of VBAC (when compared to an elective cesarean section) beyond the normal risks of having a vaginal birth? The patient should be counseled:

1)    The biggest risk is that she will need a repeat cesarean section during her labor;

2)    If she needs a cesarean section during her labor, she has a greater risk of infections and a greater need for blood and/or blood product transfusion;

3)    There is the possibility that she might need emergency anesthesia. This carries a higher risk then routine anesthesia;

4)    There is a 1/2 to 1% risk that she could develop a uterine rupture. If she were to develop uterine rupture, other complications could happen. These complications include:

a.     The need for a hysterectomy and/or other surgery;

b.     The need for blood and/or blood product transfusions;

c.     Injury or death to her baby (Approximately 1 out of 2000 babies are injured or die because their mothers have tried a VBAC.).

 

What are the benefits of having an elective cesarean section? The patient should be counseled:

1)    She has more control over the planning and timing of her baby’s birth;

2)    She may have the opportunity to schedule the date of the her baby’s birth;

3)    She may avoid labor;

4)    She nearly eliminates (but not entirely eliminates) the risk of uterine rupture.

 

What are the disadvantages / risk of having an elective cesarean section? The patient should be counseled when compared to a successful VBAC:

1)    The recovery time is longer;

2)    She may require more pain medicines after her baby’s birth;

3)    She has the risks of major surgery (these include but are not limited to bleeding, infection, damage to internal organs and/or structures);

4)    Babies born by elective cesarean section may have a harder time transitioning to newborn life and are at increased risk for short-term breathing problems;

5)    Every cesarean section that she has increases the risk that with future pregnancies she might develop placenta previa and/or placenta accreta.

 

 

In patients who are considering VBAC, overall they should be told that the overall success rate is 65-80%. There are subsets of patients who do not have this success rate. If possible, providers should discuss the prognosis for a successful VBAC with the patient when that patient’s individual characteristics are known. The table below lists various success rates as functions of patient characteristics.²

 

 

If a patient has a low chance of success, and she still desires/insists on a trial of labor, then the provider(s) must document that the patient was counseled concerning the higher risk of failure and despite this the patient choose a course that was against the provider(s) advice.

 

 

Factors that increase the change of success of a VBAC include:

1)    Having a history of a cesarean birth for a reason that is not likely to happen again (e.g. breech);

2)    Having already had one vaginal birth in the past;

3)    Having at least 18 months between the date of the last cesarean birth and the due date for this pregnancy;

4)    Having labor that occurs naturally or on its own (without medications to stimulate contractions);

5)    Having a pregnancy that is less than 40 weeks.

 

Factors the decrease the chance of success of a VBAC include:

1)    Having an induction of labor;

2)    Having more than one cesarean section (Most providers will not offer an attempt at VBAC if a women has two or more previous cesarean sections.);

3)    Having extreme obesity;

4)    Having a shorter height;

5)    Being of older age;

6)    Having the previous cesarean section done during the second stage of labor secondary to dystocia.

 

Documentation Requirements

1)    At the nursing intake visit, the nurse should:

a.     Identify the patient and provide the patient with the VBAC information sheet(s);

b.     Work with the patient to obtain the surgical report / medical history surrounding the patient’s cesarean section.

2)    At the new physician visit, the provider should review the patient’s history and cesarean section documentations.

3)    At the new physician visit, the provider should:

a.     Review the sheet with the patient;

b.     Discuss the options with the patient;

c.     With the patient, sign the information sheet;

d.     Document in the obstetrical record the discussion and signing;

                                                    i.     Document in the progress note;

                                                  ii.     Place entry in problem list;

e.     Make a copy of the sheet for the record and give the original to the patient.

4)    All patients who are cared for in our health department obstetrical clinics or at the Lincoln Community Health Center should have a consultation Duke for the above discussion.

5)    If the patient is not identified as a possible VBAC candidate during the first visit  but later she is, then the above should occur as soon as possible during her antenatal care.

6)    At 35 to 37 weeks’ gestation;

a.     If the patient is opting for repeat cesarean section;

                                                    i.     Her cesarean section should be scheduled for ≥ 39 0/7 weeks’ gestation (Please see below for when it is appropriate to schedule the elective repeat cesarean section before 39 0/7 weeks’ gestation.);

                                                  ii.     The patient should also be scheduled for a “lab only” visit to occur 1 day prior to her surgery. This is so she can have the appropriate blood tests done before her surgery. We have instituted this so on the day of her surgery, there are no delays due to her blood work not being done. This applies to ALL patients being care for at ALL sites.

b.     If the patient is considering VBAC;

                                                    i.     The patient’s information sheet should again be reviewed with her;

                                                  ii.     This discussion should be documented in the patient’s obstetrical record.

 

ACOG Guidelines for scheduling an elective delivery³

The patient should be ≥ 39 0/7 weeks’ gestation. If she is not or if her dating is poor, it is recommended that prior to performing an elective delivery (induction or cesarean section):

1)    She have an amniocentesis to document fetal lung maturity;

2)    She has developed labor;

3)    She has ruptured membranes;

4)    She has a medical and/or obstetrical condition that by delaying her delivery until ≥ 39 0/7 weeks’ gestation would place her or her fetus at increased risk of morbidity or mortality.

 

Confirmation of Term Gestation

Anyone of the following reasonably ensures that the patient is ≥ 39 0/7 weeks’ gestation. The patient must have at least one of these criteria:⁴

1)    Fetal heart tones have been documented for

a.     For 20 weeks by nonelectronic fetoscope;

b.     or for 30 weeks by Doppler.

2)    It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test was performed by a reliable laboratory;

3)    An ultrasound measurement of the crown-rump length, obtained at 6-12 weeks, supports a gestational age of at least 39 weeks;

4)    An ultrasound obtained at 13-20 weeks confirms the gestational age of at least 39 weeks determined by clinical history and physical examination.

a.     This means that the ultrasound must be in agreement with the patient’s LMP and first/second trimester uterine sizing exam.

b.     If there is disagreement, then the errors inherent to the ultrasound, history, and exam preclude stating with confidence that the patient is ≥ 39 weeks’ gestation.

5)    Although not in the ACOG practice bulletin, the following criteria would also allow confirmation of gestation (also, most of these patients would have one or more of the above criteria);

a.     The patient has undergone assisted reproductive technology and has 38 weeks have passed from an intrauterine insemination or timed intercourse;

b.     The patient has had an IVF cycle and 37 47 weeks or 263 days have passed from embryo transfer. (38 0/7 weeks or 266 days post conception).

 

References

1.       ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol 2004;104:203-12.

2.       Landon MB, Leindecker S, Spong CY, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005;193:1016-23.

3.       ACOG Educational Bulletin no. 233: Assessment of Fetal Lung Maturity. Washington, DC: American College of Obstetricians and Gynecologists; 1996.

4.       ACOG Practice Bulletin no. 10: Induction of Labor. Washington, DC: American College of Obstetricians & Gynecologists; 2001.

 

 

 

 

 

The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.

 

Prepared in conjunction with the

Division of Maternal-Fetal Medicine

Duke University Medical Center

 

                                                                                                                                    Director 

                                                                      6/20/08                                                              Date 

 

 

 

 

 

 

 

 

 

These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions.  We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.

The protocols remain the intellectual property of the Duke University Health System.  They cannot be reproduced in whole or part without the expressed permission of the Health System.

 

These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia.  Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.