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Vaginal Birth After Cesarean (VBAC). The Changing Tide. What Are Hospital Policies?. About 30% of all US hospitals in US had VBAC bans prior to the recently revised guidelines by ACOG. Many WV hospitals say they will offer VBAC but rates have dramatically decreased in

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Presentation Transcript

What are hospital policies l.jpg
What Are Hospital Policies?

  • About 30% of all US hospitals in US had VBAC bans prior to the

    recently revised guidelines

    by ACOG.

  • Many WV hospitals say they

    will offer VBAC but rates have

    dramatically decreased in

    WV prior to revised guidelines.


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National Rise in Cesarean Deliveries

  • 1970s – Less than 5% cesarean rate

  • 1970 - 3% VBAC rate

  • 1988 – cesarean delivery rate was 25%

  • 1996 - 40-50% of women attempted VBAC

  • 2002 - few as 20% of patients

    with a prior cesarean delivery

    attempted a trial of labor


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Trial of Labor

  • ACOG defines TOLAC as:

    • Safe and appropriate for

      most women with previous

      cesarean delivery,

    • Should be the woman’s choice

    • Appropriate for some women with 2 previous low transverse incisions.

    • Twin pregnancies

    • Unknown type of uterine scar


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Advantages of TOLAC

  • Meets Maternal preference

  • Reduced maternal morbidity

  • Lower risk for hemorrhage

  • Lower risk for infection

  • Faster postpartum recovery

  • Avoid future risks of multiple cesarean’s

    • Hysterectomy

    • Bowel and bladder injury

    • Transfusion

    • Infection

    • Abnormal placenta


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Increased chance of success

Prior vaginal delivery

Prior VBAC

Spontaneous labor

Favorable cervix

Nonrecurring indication (breech, previa, herpes)

Decreased chance of Success

Maternal obesity

Short stature

Macrosomia

Over 40 years

Induction of labor

Preterm delivery

Recurring indications (CPD, failed 2nd stage, interpregnancy wt. gain, gestational age over 41 weeks, diabetes, certain race/ethnicity)

TOLAC


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Risk of Uterine Rupture

  • Classical - although data are limited 6% - 12%

  • Kronig – (low vertical) 0.8% – 1.3 %

  • Kerr – (low transverse) 0.3% - 1%

  • Two prior uterine incisions - 1.8% - 3.7%

  • Prior vaginal delivery - 0.2%

  • No prior vaginal delivery - 1.1%

  • Less time between deliveries – 2.5 % – 3%


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Tipping the Scale in Favor of TOLAC

  • Woman desires more children


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Managing Women in TOLAC

  • Acute abdominal pain

  • Pain persist beyond contractions

  • A popping sensation

  • Palpation of fetal parts outside

    the uterus upon Leopold maneuver

  • Repetitive or prolonged fetal

    health rate deceleration

  • High presenting part upon

    vaginal examination

  • Vaginal bleeding


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Reasons to Consider TOLAC

  • No abdominal surgery

  • Shorter recovery period

  • Lower risk of infection

  • Less blood loss

  • For women planning to have more children, VBAC may help them avoid problems linked to multiple cesarean deliveries, hysterectomy. Bowel/bladder injury, placenta problems


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World Health Organization’s Six Healthy Birth Practices to help prevent the first C-section

  • Let labor begin on its own.

  • Encourage woman to walk, move around, and change positions throughout labor.

  • Encourage woman to bring a loved one, friend, or doula for continuous support.

  • Avoid interventions that are not medically necessary.

  • Avoid delivery with woman on her back,

  • Encourage woman to follow body's urges to push.

  • Keep mother and infant together; it is best for mother, infant, and breast-feeding.


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The Challenge

  • Educate the woman so she can make an informed decision

  • Help women lower her risk for a first cesarean

  • Find that “sweet spot”

  • Use medical interventions only when truly beneficial to mother and baby


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WV Perinatal Partnership Advises

  • Establish TOLAC guidelines within practice and within hospital

  • Educate practice employees on guidelines

  • Educate hospital employees on guidelines

  • Provide complete educational materials for pregnant women at first visit

  • Discuss guidelines throughout prenatal visits

  • Utilize informed consent documents

  • Listen to women patients


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Vaginal Birth After C-Section

  • To reorder Patient Education Pamphlets in packs of 50, please call 800-762-2264 or order online at sales.acog.org.

  • The American College of Obstetricians and Gynecologists409 12th Street, SWPO Box 96920Washington, DC 20090-6920