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VAGINAL BIRTH AFTER VAGINAL BIRTH AFTER

CC--SECTIONSECTION

Tevfik Yoldemir MD, BBA, MMktg

Marmara University

Department of Obstetrics and Gynecology

VBAC

• Success rate of VBAC 60 - 90%

• VBAC is reported to be safe

• VBAC has helped to stabilise CS rate in

US & Canada

• HENCE, birth of the latest obstetric

controversy

BENEFITS OF VBAC

• Shorter hospital stay

• Avoiding an operation, hence operative &

anaesthetic complications

• No additional scar, further vaginal births

are possible

• psychosocial

RISKS OF VBAC

– Failure

– Uterine rupture

• Hysterectomy

• Fetal hypoxia / death

RISKS OF REPEAT CS

– Operative complications: including

hysterectomy

– Anaesthetic complications

– Thromboembolism

– Infection

– blood transfusion

– Praevia

MAJOR ISSUES

• Can we identify women who are likely to succeed in VBAC and not rupture

the uterus?

• Can we manage uterine rupture?

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PREDICTORS OF SUCCESSFUL VBAC

• Scoring systems developed

• Higher success associated with:

– Previous breech presentation

– Prior vaginal delivery

– Spontaneous labour

CONDITIONS LOWERING VBAC SUCCESS

• Previous dystocia

• Previous CPD

• No prior vaginal delivery

• >1 previous CS

• Oxytocin use

• Induction of labour

• Non reassuring admission CTG

UTERINE RUPTURE

• Gradation: dehiscence ↔ rupture

• 1% of VBAC after LUSCS– Types (NB myomectomy) / number of scars

• 1 LUSCS: 0.5%

• 2 LUSCS: 2%

• Classical: 4 – 9%

• Induction with PG: 2%

• Mistoprostol induction: 12%

• VBAC is only offered to women who have had 1 previous LUSCS

MANAGEMENT OF VBAC

• High risk labour

• May be – prostaglandins, oxytocin

• IV access, blood cross-matched (should)

• Continuous fetal heart rate monitoring

• Close review of progress of labour

• Regional analgesia NOT contraindicated, but beware of break through pain in the presence of a previously functioning epidural

• Availability of medical staff to perform emergency caesarean delivery

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Recommendations of ACOG (1999) for

selection of candidates for vaginal birth after

cesarean delivery (VBAC)

Selection Criteria

One or two prior low-transverse cesarean deliveries

Clinically adequate pelvis

No other uterine scars or previous rupture

Physician immediately available throughout active labor

capable of monitoring labor and performing an emergency cesarean delivery

Availability of anesthesia and personnel for emergency cesarean delivery

Type of prior uterine incision

Type of uterine incision Estimated rupture(%)

Classical

T-shaped

Low-vertical

Low-transverse

4-9

4-9

1-7

0.2-1.5Number of prior cesareansNumber of prior cesareans Estimated rupture(%)

1

2

0.8

3.7

Contraindication: prior classical or Tprior classical or Tprior classical or Tprior classical or T----shaped uterine incisionshaped uterine incisionshaped uterine incisionshaped uterine incisionIndication for prior cesarean

Julie G. etc Obstetrics and gynecology vol. 103. No.3. March 2004Obstetrics and gynecology vol. 103. No.3. March 2004Obstetrics and gynecology vol. 103. No.3. March 2004Obstetrics and gynecology vol. 103. No.3. March 2004Good predictor Poor predictor

Prior vaginal delivery Prior cesarean delivery for dystocia

Induction on or past the estimated date of delivery

Need for cervical ripening

Maternal gestational or preexisting diabetes

Oxytocin and epidural analgesia

• Several studies attest to the safety of properly conducted

epidural analgesia

(Farmer etc. 1991; Flamm etd. 1994)

labor Uterine rupture (%)

Induction

Augmentation

Spontaneous

2.3 %

1 %

0.3 %

Risk of uterine rupture in labor induction of patients

with prior cesarean section: An inner city hospital

experienceCarol Lin, etc. Am J obgyn (2004) 190,May

• 1996-2002, total 3533 patients

Rupture rate

Overall rate 0.5 % (19/3533)

Repeat cesarean group(n=438) 0.2 % (1/438)

Spontaneous labor group (n=2523) 0.4 % (11/2523)

Oxytocin induction (n=430) 1.2 % (5/430)

Misoprostol induction (n=142) 1.4 % (2/142)

Trial of labor in patients with a previous cesarean section: Does maternal age influence the outcome?Emmanuel Bujold, etc. Montreal, Quebec, Canada

Am J Obgyn 2004.vol.190

• 1988-2002

• 2493 Pts who trial of labor after a prior cesarean delivery

• 1750 without a prior vaginal delivery and 743 with a prior vaginal delivery

• Conclusion: Patients who are Patients who are Patients who are Patients who are 35 years or older are more 35 years or older are more 35 years or older are more 35 years or older are more prone to have a failed TOL after a prior cesarean deliveryprone to have a failed TOL after a prior cesarean deliveryprone to have a failed TOL after a prior cesarean deliveryprone to have a failed TOL after a prior cesarean delivery. . . .

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The impact of a single-layer or double-layer closure

on uterine ruptureEmmanuel Bujold, MD,a Camille Bujold, OT,a Emily F. Hamilton, MD,b François

Harel, MSc,a and Robert J. Gauthier, MDa

Montreal, Quebec, Canada

Am J Obstet Gynecol 2002;186:1326-30.

• STUDY DESIGN: This is an observational cohort study of all women

undergoing a trial of labor from 1988 to 2000 in a tertiary care center, after a single low transverse cesarean delivery.

• RESULTS: Of the 2142 women who met the study criteria, 1980 (92.4%)

had maternal records and original operative reports reviewed. After adjustments were made for confounding variables, the odds ratio for uterine

• rupture in women with a single-layer closure was 3.95 (95% CI, 1.35-11.49).

• CONCLUSION: A single-layer closure of the previous lower segment incision was the most influential factor and was associated with a 4-fold

increase in the risk of uterine rupture compared with a double-layer closure.

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