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

ACOG # 115 2010

Validate/Reference well performed studies & present a range of data (+/-) emphasizing that it may be reasonable to expand the CANDIDATE POOL. Extreme caution should STILL be exercised when considering additional factors @ term which may influence the success or failure of VBAC THE MOST CLINICALLY USEFUL INFORMATION IN THE NEW BULLETIN TOLAC COUNSELING CALCULATOR MORTALITY /MORBIDITY % tge TABLES

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

WHO ARE NEW TOLAC CANDIDATES

TWO previous low transverse uterine incisions Ok Twins Ok ECV Ok EGA > 40 weeks Ok One Low vertical Ok Suspected Macrosomia alone Ok Informed induction Ok however NO prostaglandins followed by oxytocin. ( Foley bulb followed by pitocin ) Undocumented scar with out history suggesting classical c/s ACOG PRACTICE BULLETIN AUGUST Number 115, 2010

Contraindications for VBAC

Prior classical or T-shaped uterine incision or extensive transfundal uterine surgery (eg, myomectomy) Previous uterine rupture (the frequency of repeat rupture varies from 6 to 32 percent, respectively if the lower uterine segment or the upper segment was the site of the initial rupture) No Cytotec Medical or obstetrical complications that preclude vaginal birth (eg, placenta previa) Inability to immediately perform emergency cesarean delivery due to factors related to the facility, surgeon, anesthesia, or nursing staff

Two or more prior uterine scars and no prior vaginal deliveries. 2010 REMOVED two previous c/s and remained silent regarding previous vaginal delivery
ACOG VBAC Bulletin # 54 JULY 2004

/ 2010 #115

Uterine Rupture By Incision Location

The rate of rupture reported by incision location is: Classical (4 to 9 %) T-shaped (4 to 9 %) Low vertical (1 to 7 %) 1 Low transverse ( 0.7 to 0.9 %) 2 Low transverse ( 0.9-1.8 % )

2 previous C/S
Candidates but Counsel Carefully
Two large studies referenced by ACOG, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC. One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries , whereas the other noted a risk of Uterine Rupture that increased from 0.9% to 1.8% ( 2X ) in women with one versus two prior cesarean deliveries Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2%) composite major morbidity in one study

2 PREVIOUS C/S ACOG 2010

The chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC

Do Not forget to Counsel based on the combination of other factors that affect the probability of achieving a successful VBAC.

Maternal Factors Associated VBAC SUCCESS

Young maternal age Increased height Body mass index <30 kg/m2 Non-Hispanic white ethnicity Favorable cervix &/Or Spontaneous Labor Gestational age <40 weeks. Birthweight <4000 g The rate of success increases as the number of prior VBAC successes increases

Maternal Factors Associated VBAC FAILURE

Recurrent indication for initial cesarean delivery Increased maternal age Non-white ethnicity Gestational age greater than 40 weeks Maternal obesity Preeclampsia Short interpregnancy interval Increased neonatal birth weight

TOLAC/VBAC SUCCESS COUNSELING CALCULATOR 2010 ACOG

A model was developed specifically for women undergoing TOLAC at term with one prior low transverse cesarean delivery incision, singleton pregnancy, and cephalic fetal presentation. This model may have utility for patient education and counseling for those considering TOLAC at term

VAGINAL BIRTH AFTER CESAREAN

Height & weight optional; enter them to automatically calculate BMI

no age 25 Maternal18

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
5 FOOT 3 INCHES 225 LBS HISPANIC NO PREVIOUS VAGINAL DELIVERY PREVIOUS C/S FOR CPD

Predicted chance of vaginal birth after cesarean: 24.5% 95% CI: [21.3%, 28.1%]

CONSIDER THE RESULTS

Consider additional Information
It is designed for educational use and is based on a population of women who received care at the hospitals within the MFMU Network. Responsibility for its correct application is accepted by the end user. "Development of a nomogram for prediction of vaginal birth after cesarean delivery," Obstetrics and Gynecology, volume 109, pages 806-12, 2007.

ACOG/TOLAC CALCULATOR ACOG 2010

Although there is no universally agreed on discriminatory point, evidence suggests that women with at least

6070% chance of VBAC

Have equal or less maternal morbidity when they undergo TOLAC than women undergoing elective repeat cesarean delivery

ACOG/TOLAC CALCULATOR ACOG 2010

Less than or Equal to 60% probability TOLAC RISK outweigh the potential benefit
Failed VBAC is associated with a greater chance of NEONATAL AND MATERNAL MORBIDITY than woman undergoing elective repeat cesarean delivery

The MFMU Cesarean Registry:

Prospective study with > 14,500 vbac attempts

The overall VBAC success rate in obese women (BMI > or = 30) was lower (68.4%) than in non obese women (79.6%) (P < .001) When combined with induction and lack of previous vaginal delivery, successful VBAC occurred in only 44.2% of cases.
Am J Obstet Gynecol 2005 Sep;193(3 Pt 2):1016-23

Success for VBAC by History

PREVIOUS VAGINAL DELIVERY Yes / 85% success No / 60% success

PREVIOUS VBAC DELIVERY Yes / 85% success No / 65% success

CERVIX 4 CM ON ADMISSION Yes / 85 % success SPONTANEOUS LABOR

Am J Obstet Gynecol 2005; 193:1016

No / 65% success 80% success

Success for VBAC by history

Previous non recurring indication 75-85 % 50-80% 80% 70%

All pts with DYSTOCIA as indication

Latent phase C/S (4cm or less) Active phase C/S ( 5 to 9 cm )

Second stage C/S (10 & pushing) 10%

ACOG VBAC BULLETIN # 54 2004

Increase BMI > 39 = Increased risk

A BMI > 39 was associated with greater composite maternal morbidity and neonatal injury compared with elective repeat cesarean delivery Increasing BMI was directly associated with failed trial of labor after previous cesarean delivery BMI > 39 TOLAC WAS ASSOCIATED WITH 5 X risk of uterine rupture (2.1% vs 0.4%), 5 X risk of neonatal injury (1.1% vs 0.2%) 2 X risk of Maternal Morbidity (7.2% versus 3.8%)

Obstet Gynecol. 2006 Jul;108(1):125-33 MFMU

VBAC Safety and Success AT OR Beyond 40 weeks of gestation

There is a 4% increased risk for a failed VBAC @ 35 % @ 41 weeks vs 31 % @ 40 weeks ~ 65 % successful VBAC @ 41 weeks The risk of overall maternal morbidity IS not clinically or statistically significant when comparing after 41 vs 40 weeks (2.7% @ 41 weeks compared with 2.1% @ 40 0/7 weeks).

Obstet Gynecol. 2005 Oct;106(4):700-6

40 WEEKS OR GREATER
Although chances of success may be lower( 4%) in
more advanced gestations, gestational age of greater than 40 weeks alone should not preclude TOLAC. Use calculator to help you decide Be cautious and include OTHER PERTINENT risk factors for VBAC failure or increased risk for uterine rupture with TOLAC in this situation such as Interdelivery interval, EFW ( > 3600 grams) , & Bishop score, Previous C/S indication, ACOG 2010 #115

4000 GRAMS MACROSOMIA

Some limited evidence also suggests that the uterine rupture rate is increased (relative risk 2.3, P<.001) for women undergoing TOLAC without a prior vaginal delivery and neonatal birth weights greater than 4,000 g. It remains appropriate for health care providers and patients to consider past and predicted birth weights (ie sono for efw if suspicious) when making decisions regarding TOLAC, but suspected macrosomia alone should not preclude the possibility of TOLAC.

TWINS
Women with twin gestations had a similar chance of achieving VBAC as women with singleton gestations and did not incur any greater risk of uterine rupture or maternal or perinatal morbidity. Women with one previous cesarean delivery with a low transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC.

INDUCTION/AUGMENTATION
Induced labor is less likely to result in VBAC than spontaneous labor, ESPECIALLY with an unfavorable cervix. Therefore, selecting women most likely to give birth vaginally while avoiding sequential use of prostaglandins and oxytocin appears to have the lowest risks of uterine rupture. The varying outcomes of available studies and small absolute magnitude of the risk reported in those studies support that oxytocin augmentation may be used in patients undergoing TOLAC. 1% risk of rupture with oxytocin augmentation Induction utilizing mechanical dilation ( Foley Bulb distended to 40 ml more effective or @ least as effective as Cytotec in RCT) may be an option for TOLAC candidates with an unfavorable cervix.

COUNSELING RISK OF UTERINE RUPTURE

Spontaneous labor 0.9% 1 c/s vs 1.8% for 2 Induced TOLAC Pitocin Augmented 1% - 2.4% 1%

ACOG Number 115, August 2010 N Engl J Med. 2001 Jul 5;345(1):3-8.

N Engl J Med 2004;351:25819 Am J Obstet Gynecol 1999;181:882

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

Prior single-layer closure may be associated with a two fold or higher risk of uterine rupture compared with double-layer closure. Single-layer closure should be avoided in women who could contemplate future vaginal birth after cesarean delivery. Bujold E Bujold E Obstet Gynecol. 2010 Jul;116(1):43-50
Am J Obstet Gynecol. 2002;186(6):1326-30

Controversy Regarding Closure of the Uterus

Only one Author (Bujold E) has demonstrated an increased risk of uterine rupture with single vs two layer closure in two separate retrospective studies. No proven physiologic/biologic models. Inclusion of endometrium in animal studies may be associated with adenomyosis and interfere with scar formation ; However Never been demonstrated to effect scar integrity. Hypoxia and/Or vascular occlusion may result in poor tissue healing? Locking vs Running uterine closure? Or Multiple hemostatic figure of 8 sutures? Never been demonstrated to effect scar integrity .

Short Interdelivery Interval

Time elapsed from previous delivery date to current TOLAC
Multiple studies have demonstrated that an Interdelivery interval < or = to 18 months may be associated with a two fold or higher risk of uterine rupture during TOLAC. Furthermore it appears that a shorter Interdelivery interval is associated with a greater than two fold risk of rupture.
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;183:11801183

If Uterine Rupture Occurs with Immediately Available Team

Risk of HIE 10-11% @ worse case estimate (95% confidence interval, 1.810.6%) Neonatal death ~ 5% @ worse case estimate (95% CI, 04.2% ) Maternal risk of ~ 10 % for Transfusion 5% risk for TAH ; 30 % for TAH with Catastrophic Rupture
ACOG Number 115, August 2010 N Engl J Med 2001;345:3-8

Maternal Risks

ERCD (%)

TOLAC (%) One CD Two CDs 3.1 0.4

Endometritis Operative injury

1.52.1 0.42.6

2.9 0.4

Blood transfusion
Hysterectomy Uterine rupture Maternal death

11.4
00.4 0.40.5 0.020.04

0.71.7
0.20.5 0.70.9 0.02

3.2
0.6 0.91.8 0

ACOG Number 115, August 2010

Neonatal risk
Short term respiratory transitional needs ~ 2 x as high with ERCD vs successful VBAC Hyperbilirubinemia ~ 2 x as high with ERCD vs successful VBAC Neonatal morbidity is higher in the setting of a failed TOLAC than with successful VBAC
( therefore < 60% success not recommended for TOLAC)

Perinatal mortality is higher( includes stillbirth) with TOLAC vs ERCD ; however the absolute risk is ~ 1/10 of 1%
ACOG Number 115, August 2010 N Engl J Med 2004;351:25819

Neonatal Risks
IUFD 3738 weeks IUFD 39 weeks or greater HIE Neonatal death

ERCD (%)
0.08 0.01 0013 0.05

TOLAC (%)

0.38 0.16
0.08 0.08 NS

Perinatal death
Neonatal admission

0.01
6.0

0.13
6.6

HYPOXIA
NS

Respiratory morbidity
Transient tachypnea Hyperbilirubinemia

1 5
6.2 5.8

0.11.8
3.5 2.2

DOCUMENTATION MANDATORY
Documentation of counseling and the management plan should be included in the medical record. Potential benefits and risks ( % ) of both TOLAC and elective repeat cesarean delivery should be discussed and documented. The VBAC SUCCESS CALCULATOR AND MATERNAL /NEONATAL RISK TABLES provided by ACOG facilitate a STANDARDIZED discussion that is patient specific and ENDORSED by ACOG. After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her healthcare provider.

Dr Montgomery Recommends
DOCUMENT COUNSELING WIH QUOTED RISK/BENEFIT % tges TOLAC CALCULATOR : No < 60 /60-69 Offer/ 70 or > Recommend Additionally consider interdelivery interval during antenatal calculation DO RECOMMEND For a patient who has requested TOLAC a scheduled repeat cesarean section by 41 0/7 weeks with success calculated @ 70% For a patient who has requested TOLAC a scheduled repeat cesarean section by 40 0/7 weeks with success calculated @ < 70% REMEMBER EFW & modified Bishop Score as you approach 38 weeks Thoroughly counsel about induction or augmentation taking into account additional factors associated with failure and/or increased risk. DO RECOMMEND SCHEDULED REPEAT CESAREAN SECTION @ 39 WEEKS FOR PATIENTS WHO DECLINE TOLAC; Due to the documented increased risk of IUFD after 39 weeks. DO NOT recommend TOLAC for patients with a history of failure of descent (previously dilated to 10 cm) >/= to 85 % will have a failed VBAC Schedule C/S @ 39 0/7 weeks for these patients. DO NOT recommend TOLAC For patients with a BMI of 39 or greater. Schedule C/S @ 39 0/7 weeks for these patients.