Download Trial of Labor After Cesarean a brief history, what to say to

Trial of Labor After Cesarean
Carrie Griffin DO
May 3rd, 2017
Objectives
• Review the historical course of VBAC
• How to counsel patients regarding risks of
TOLAC and likelihood of successful VBAC
• Labor management of TOLAC and its
complications
• Preventing the need for a TOL
To start….
Marisa is a 26 yo G3
P2002 at 26 wks based on
a 7 wk US who is
interested in TOLAC
Brief History
In a 1916 article entitled “Conservatism in
Obstetrics” Edward Cragin famously writes
“once a Cesarean section, always a Cesarean”
By the 1970s, with the advent of blood
transfusions, perioperative antibiotics, a shift in
surgical practice, EFM, fewer vaginal breech
births and fewer instrumented deliveries led to a
higher CS rate of 16.5% by 1980
• 1984 ACOG encourages TOL
• 1988 ACOG states that “the concept of repeat
Cesarean birth should be replaced by a
specific indication for a subsequent abdominal
delivery”
• 1996 McMahon et al study in NEJM suggests
VBAC riskier than initially surmised
VBAC-lash
McMahon et al NEJM 1996
ACOG 1999 VBAC Opinion
“ Because uterine rupture may be catastrophic,
VBAC should be attempted in institutions
equipped to respond to emergencies with
physicians immediately available to provide
emergency care”
NIH VBAC Conference 2010
Found that increase in perinatal mortality from
TOLAC is “small and comparable to the perinatal
mortality rate observed among laboring nulliparous
women”
Increased rates of placenta previa and invasive
placentation in women having a third cesarean
There are not enough anesthesia providers to
ensure “immediate availability” to all labor &
delivery units
NIH VBAC Conference 2010
• Voiced concern about barriers to VBAC and
recommended that hospitals, providers,
insurers and patients collaborate to develop
services and strategies to mitigate existing
barriers
• Asked for ACOG to revisit its immediate
availability recommendation
ACOG 2010 Practice Bulletin
• “When resources for immediate Cesarean delivery are
not available, the College recommends that health care
providers and patients considering TOLAC discuss the
hospital’s resources and availability of obstetric,
pediatric, anesthetic and operating room staffs.”
• “Respect for patient autonomy supports that patients
should be allowed to accept increased levels of risk,
however, patients should be clearly informed of such
potential increase in risk and management
alternatives.”
Which of these women is not a candidate for a
TOLAC?
a)
b)
c)
d)
e)
Woman with twin pregnancy and 1 prior CS
Vertical skin incision
BMI of 48
Classical uterine incision
Woman with a history of pre-eclampsia and 2
prior CS
ACOG 2010 TOLAC Eligibility
• NO TOLAC IF
– Classical or T incision
– Extension of incision into
contractile portion of
uterus
– Full thickness
myomectomy
• OK IF
– 1 or 2 prior LTCS
– Twins with single prior
LTCS
– > 40 wks
– Macrosomia
– Prior low vertical incision
– Unknown uterine scar
Marisa is a 26 yo G3
P2002 at 26 wks based on
a 7 wk US who is
interested in a TOLAC
•
•
•
•
•
•
Prior obstetric history
Request and review prior operative report
Counsel regarding risks and benefits of TOLAC
Understand what local hospital capabilities are
Sign TOLAC consent prenatally
Continue to readdress decision with patient if
change in risk factors, when presents in labor
and throughout labor process
Maternal Risks from ERCS vs TOLAC
Neonatal Risks after ERCS vs TOLAC
Neonatal Risk of TOLAC
• Landon et al NEJM 2004 study of 17,000 +
women which reviewed neonatal outcomes of
HIE and death
• HIE occurred in no infants whose mothers
underwent ERCS and in 12 infants whose
mothers had a TOLAC
– 7 of these 12 were following uterine rupture
– 2 neonatal deaths
Maternal Advantages
• Avoid major abdominal surgery
• Lower rates of hemorrhage, infection
• Shorter recovery time
Neonatal Advantages
• Vaginal birth associated with less respiratory
distress of the newborn, greater likelihood of
early initiation of breastfeeding and skin to
skin contact
Risks of multiple cesareans
•
•
•
•
•
Placenta previa
Placenta accreta
Severe adhesive disease
Bladder and bowel injury
Emergency hysterectomy
The best predictor of a successful VBAC is
a)
b)
c)
d)
e)
Really, really wanting one
BMI < 30
Hispanic
Spontaneous labor
History of a prior VD
Predictors of Success
Increased Likelihood
Decreased Likelihood
Prior vaginal birth before or after CS
No prior vaginal deliveries
Admitted in active labor
Labor induction
Fetal weight < 4000 gm
Macrosomia
Prior Cesarean for nonrecurring cause
(previa, breech)
Prior Cesarean for second stage arrest
BMI < 30
Obesity
Non-hispanic white
Hispanic or African-American
VBAC Scoring Systems
• 74% success rate
• Individual factors usually still leave women in
60-80% success category unless she has had a
prior vaginal birth
• Grobman nomogram most commonly used
Grobman nomogram
no
25
18
Calculate
Marisa scores a….
Predicted
chance of
VBAC:
81.9%
If she had not had a prior VD
Predicted
VBAC now
65.1%
And if Marisa were not Hispanic…
Predicted
VBAC success
now 90.1%
Uterine Rupture
Risk Stratification for Uterine Rupture
•
•
•
•
Type of uterine incision
Multiple prior cesareans
Interval since last cesarean
# layers of uterine closure
Uterine Rupture Rate Based on Type of
Incision
•
•
•
•
Classical Incision 4 – 9%
T or J Incision 4 – 9%
Low vertical incision 1 -- 7%
Low transverse incision 0.2 – 1.5%
Risk of multiple cesareans
•
•
•
•
•
•
•
Landon et al study in 2006
4 year observational study of 45,000 + VBAC
0.9% rate of rupture with multiple CS
0.7% rate of rupture with 1 prior
66% successful VBAC with multiple CS
74% success rate with 1 prior
Higher risk of transfusion and hysterectomy if
multiple CS
Cesarean Interval
• Interval of < 6 months between Cesarean and
conception shown to have an odds ratio of
2.66 for uterine rupture
Uterine Closure Technique
• Mixed data but 2014 meta-analysis of 14
studies did not show a difference in uterine
rupture rates between single and double
uterine closures
Called by the junior night float resident and
learn that Marisa is having contractions every 34 minutes and is 6 cm and being admitted for
labor
Intrapartum Management
•
•
•
•
Type and screen all TOLAC patients
IV access
Continuous fetal monitoring
Immediate availability of surgeon, anesthesia
and OR staff
• Routine use of IUPC with or without oxytocin
usage does not decrease uterine rupture rates
Which of the following should be avoided in
labor induction or augmentation in TOLAC
patients?
a)
b)
c)
d)
e)
Pitocin
Foley bulb
Misoprostol
Evening primrose oil
Nipple stimulation
TOLAC Induction
• Avoid elective induction
• No misoprostol – unclear if other
prostaglandins carry same risk
• Balloon catheters + “slow” pitocin
• Continue to readdress risks & viability of
successful VBAC throughout induction
Marisa is now 8 cm and you head in to the
hospital. When you arrive her strip looks like
this:
Diagnosis of Uterine Rupture
•
•
•
•
•
Sudden and constant pain
Vaginal bleeding
Loss of uterine contractions
Elevation of presenting part
Typically however fetal distress seen first on
EFM (70% of cases this is initial indication)
Management of Uterine Rupture
• Fetal resuscitation techniques still apply
including prompt delivery of fetus which may
necessitate CS
• Ensure adequate IV access, neonatal providers
available
• Some evidence that best neonatal outcomes
occur if delivery occurs within 17 min of fetal
distress appearing on monitor
Tracing improves and now has only intermittent
late decels and moderate variability. Marisa is
complete and pushes for 80 minutes to deliver a
viable female with Apgars of 8 and 9
Prevention….
Prevention for Stage 1 of Labor
• Strict adherence to definitions for AOL
– Latent labor
• 24 hours of Pitocin after AROM
– Active labor
• 4 hours of adequate contractions + IUPC and pit
• 6 hours of inadequate contractions + IUPC and pit
Prevention for Stage 2 of Labor
• Again adherence to definitions of AOL
– 3 hours of pushing for primiparous
– 2 hours of pushing for multiparous women
– Longer durations acceptable if epidural analgesia
in use and if progress is being documented hourly
• Manual rotation of fetal occiput for
malposition
• Operative vaginal delivery
Key Practice Points
• Eligible if 1 or 2 prior LTCS
• Success difficult to predict but generally
between 60 to 80%
• Most major complications occur when TOLACs
end in RCS
• No misoprostol/prostaglandins; Foley/pitocin
only
• The practice of evidence based labor
management can help prevent the primary CS