VAGINAL BIRTH AFTER PREVIOUS

CESAREAN DELIVERY
ARINI ESTIASTUTI

Trial of Labor After Previous

Cesarean Delivery
TOLAC
The term trial of labor refers to atrial 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

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
Twins Gestation
ECV
EGA > 40 weeks
One Low Vertical Incision
Suspected Macrosomia alone
Informed induction however NO prostaglandins followed by
oxytocin. ( Foley Bulb followed by Pitocin )
Undocumented scar without history suggesting classical c/s

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 staf
Two or more prior uterine scars and no prior vaginal deliveries.
2010 REMOVED two previous c/s and remained silent
regarding previous vaginal delivery

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 diference 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 affet 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

ACOG/TOLAC CALCULATOR
ACOG 2010
Although there is no universally agreed on
discriminatory point, evidence suggests
that women with at least 60-70%
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

Increase BMI > 39 = Increased risk

A BMI > 39 wa 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%)

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).

40 WEEKS OR GREATER
Although chances of success may be lower (4%)
in more advance 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 provider
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 gestation had a similar
chance of achieving VBAC as women with
single gestation 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 prostaglandins and
oxytocin appears to have the lowest risks of uterine rupture.
The varing 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 efective or @ least as efective 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

1% - 2.4%

Pitocin Augmented 1%

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.

If Uterine Rupture Occurs with

Immediately Avaible Team
Risk of HIE 10-11% @ worse case estimate
(95% confidence interval, 1.8-10.6%)
Neonatal death 5% @ worse case estimate
(95% CI, 0-4.2%)
Maternal risk 10% for Transfusion
5% risk for TAH
30% TAH with catastrophic Rupture

Maternal Risk

ERCD (%)

TOLAC (%)

One CDTwo CDs

Endometritis

1.5-2.1

Operative injury
Blood transfusion
Hysterectomy
Uterine rupture
Maternal death

2.9

0.42-.6

3.1
0.4

1-1.4
0-0.4
0.4-0.5
0.02-0.04

0.4
0.7-1.7

3.2

0.2-0.5 0.6
0.7-0.9
0.02

0.9-1.8

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 ( there < 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%

Neonatal Risks ERCD (%) TOLAC(%)

IUFD 37-38 weeks

0.080.38

IUFD 39 weeks or greater 0.010.16

HIE 0-013

0.08

Neonatal death 0.050.08 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
Documentation of counseling and the management plan
should be included in the medical urecord.
Potential benefits and risks (%) of both TOLAC and
lective repeat cesarean delivery should be dicussed 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

THANK YOU