Vaginal Birth After Cesarean: Vaginal Birth After Cesarean: Is it Still an Option?Is it Still an Option?

Howard Blanchette, M.D.Howard Blanchette, M.D.Professor & ChairmanProfessor & Chairman

Department of Obstetrics & GynecologyDepartment of Obstetrics & Gynecology

New York Medical CollegeNew York Medical College

VBAC Success RateVBAC Success Rate66% to 85%66% to 85%

Minimal Neonatal or Maternal MorbidityMinimal Neonatal or Maternal Morbidity

Blanchette et al. Is Vaginal Birth after Cesarean Safe? Experience at a Community Hospital. Am J Obstet Gynecol 2001; 6:1478-87 Blanchette et al. Is Vaginal Birth after Cesarean Safe? Experience at a Community Hospital. Am J Obstet Gynecol 2001; 6:1478-87

Curtin SC. Rates of Cesarean Birth and Vaginal Birth After Previous Cesarean, 1991-95. Monthly Vital Statistics Report. Vol 45, No. 11, Suppl 3. Hyattsville Curtin SC. Rates of Cesarean Birth and Vaginal Birth After Previous Cesarean, 1991-95. Monthly Vital Statistics Report. Vol 45, No. 11, Suppl 3. Hyattsville (MD): National Center for Health Statistics; 1997. (Level II-3)(MD): National Center for Health Statistics; 1997. (Level II-3)Martin JA et al. Births: Final Data for 2002. Natl Vital StatRep 2003; 52 (10): 1-113. (Level II-3) Martin JA et al. Births: Final Data for 2002. Natl Vital StatRep 2003; 52 (10): 1-113. (Level II-3) Martin JA et al. Preliminary Births for 2004: Infant and Maternal Health. Natl Vital Stat Rep 2004. Martin JA et al. Preliminary Births for 2004: Infant and Maternal Health. Natl Vital Stat Rep 2004.

Between 1970-1988 the Cesarean delivery rate in the UnitedBetween 1970-1988 the Cesarean delivery rate in the UnitedStates increased dramatically from 5% to 25%.States increased dramatically from 5% to 25%.

From 1989-1996 the Cesarean section rate decreased to 20.7%From 1989-1996 the Cesarean section rate decreased to 20.7%while the VBAC rate increased from 18.9% to 28.3%. while the VBAC rate increased from 18.9% to 28.3%.

YearYear C- Section RateC- Section Rate VBAC RateVBAC Rate 20022002 26.1% 26.1% 12.6% 12.6%

20032003 27.5% 27.5% 10.6% 10.6%20042004 29.1% 29.1% 9.2% 9.2%20052005 30.2% 30.2%

Healthy People 2000Healthy People 2000

C-Section RateC-Section Rate 15%15% Primary Primary 12%12% Repeat Repeat 3% 3%

Healthy People 2010Healthy People 2010

Calls for a reduction in the rate of repeat Cesarean births Calls for a reduction in the rate of repeat Cesarean births from 72% in 1998 to a target of 63% in 2010.from 72% in 1998 to a target of 63% in 2010.

Healthy People 2000. Washington: Public Health Service (US). Department of Health and Human Services (US); 1991. Healthy People 2000. Washington: Public Health Service (US). Department of Health and Human Services (US); 1991.

Healthy People 2010. Washington: Public Health Service (US). Department of Health and Human Services (US); 2000. Healthy People 2010. Washington: Public Health Service (US). Department of Health and Human Services (US); 2000.

Uterine Rupture RateUterine Rupture Rate0.3% to 1.5%0.3% to 1.5%

Relative Safety of VBACRelative Safety of VBAC

Blanchette et al. Is Vaginal Birth after Cesarean Safe? Experience at a Community Hospital. Am J Obstet Gynecol 2001; 6:1478-87Blanchette et al. Is Vaginal Birth after Cesarean Safe? Experience at a Community Hospital. Am J Obstet Gynecol 2001; 6:1478-87

Uterine Rupture:Uterine separation requiring emergency laparotomy for a non-reassuring fetal heart rate tracing or maternal hemorrhage

Risk of Perinatal DeathRisk of Perinatal Death

Mozurkewich et al.Mozurkewich et al.Elective Repeat Cesarean Delivery versus Trial of Elective Repeat Cesarean Delivery versus Trial of

Labor: A Meta-analysis from 1989-1999.Labor: A Meta-analysis from 1989-1999.

TOLAC Repeat C-SectionTOLAC Repeat C-Section 38/19,84238/19,842 10/13,292 10/13,292 (0.2%)(0.2%) (0.1%) (0.1%)

OR 2.05 (CI 1.17-3.57)OR 2.05 (CI 1.17-3.57)

Although the risk of fetal or neonatal death is higher in women Although the risk of fetal or neonatal death is higher in women attempting VBAC, the absolute risk is low.attempting VBAC, the absolute risk is low.

*Mozurkewich et al. Elective Repeat Cesarean Delivery versus Trial of Labor: A Meta-analysis From 1989 to 1999. Am J Obstet Gynecol 2000; 11: 1187-97*Mozurkewich et al. Elective Repeat Cesarean Delivery versus Trial of Labor: A Meta-analysis From 1989 to 1999. Am J Obstet Gynecol 2000; 11: 1187-97

Future Risk of Elective Repeat Cesarean SectionFuture Risk of Elective Repeat Cesarean Section

Placenta PreviaPlacenta Previa 0 CD 0 CD 1 CD 1 CD 2 CD2 CD 3 CD3 CD(0.26%)(0.26%) (0.65%)(0.65%) (1.8%(1.8% )) (3%)(3%)

Placenta AcretaPlacenta Acreta 0 CD0 CD 1 CD 1 CD 2 CD 2 CD 3 CD 3 CD(0.01%)(0.01%) (0.16%)(0.16%) (0.82%)(0.82%) (1.09%)(1.09%)

A woman with two prior Cesareans has a 2% incidence of A woman with two prior Cesareans has a 2% incidence of placenta previa; nearly half of these cases are associated with placenta previa; nearly half of these cases are associated with placenta acreta.placenta acreta.

Jackson et al. Physical Sequelae of Cesarean Section. Best Prac Res Clin Obstet Gynaecol 2001; 15: 49-61.Jackson et al. Physical Sequelae of Cesarean Section. Best Prac Res Clin Obstet Gynaecol 2001; 15: 49-61.

Clark et al. Placenta Previa/Acreta an Prior Cesarean Section. Obstet Gynecol 1985; 66: 88-92.Clark et al. Placenta Previa/Acreta an Prior Cesarean Section. Obstet Gynecol 1985; 66: 88-92.

Increased Maternal Morbidity Associated with the Increased Maternal Morbidity Associated with the Increasing Number of Cesarean Deliveries Increasing Number of Cesarean Deliveries

Placenta AcretaPlacenta Acreta

1 CD 1 CD 2 CD 3 CD 4CD 5CD 6CD 2 CD 3 CD 4CD 5CD 6CD

0.24% 0.31% 0.57% 2.13% 2.33% 0.24% 0.31% 0.57% 2.13% 2.33% 6.74%6.74%

HysterectomyHysterectomy

1 CD 1 CD 2 CD 3 CD 4CD 5CD 6CD 2 CD 3 CD 4CD 5CD 6CD 0.65% 0.42% 0.90% 2.41% 3.49% 0.65% 0.42% 0.90% 2.41% 3.49% 8.99% 8.99%

The authors concluded that because of serious maternal morbidity The authors concluded that because of serious maternal morbidity increasing progressively with increasing numbers of cesarean deliveries, increasing progressively with increasing numbers of cesarean deliveries, the number of intended pregnancies should be considered during the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of counseling regarding elective repeat cesarean operation versus a trial of labor, and when debating merits of elective primary cesarean delivery.labor, and when debating merits of elective primary cesarean delivery.

Silver et al. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstet Gynecol 2006; 107: 1226-32Silver et al. Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries. Obstet Gynecol 2006; 107: 1226-32

Complications With Cesarean Delivery vs. Complications With Cesarean Delivery vs. Vaginal DeliveryVaginal Delivery

Maternal death with Cesarean sectionMaternal death with Cesarean section 4/10,0004/10,000Maternal death with all vaginal birthsMaternal death with all vaginal births 1/10,0001/10,000Maternal death with elective Cesarean sectionMaternal death with elective Cesarean section 2/10,0002/10,000Maternal death with normal vaginal birthMaternal death with normal vaginal birth 0.5/10,0000.5/10,000

Ob/Gyn Clinical Alert. October 2004; Vol. 21, No. 6, 43.Ob/Gyn Clinical Alert. October 2004; Vol. 21, No. 6, 43.

ACOG Practice Bulletin (July 2004)ACOG Practice Bulletin (July 2004) Summary of Recommendations Summary of Recommendations

The following recommendations are based on good and consistent scientific evidence (Level A):The following recommendations are based on good and consistent scientific evidence (Level A): Most women with one previous cesarean delivery with a low-transverse incision are candidates for Most women with one previous cesarean delivery with a low-transverse incision are candidates for

VBAC and should be counseled about VBAC and offered a trial of labor.VBAC and should be counseled about VBAC and offered a trial of labor. Epidural anesthesia may be used for VBACEpidural anesthesia may be used for VBAC

The following recommendations are based on limited or inconsistent scientificThe following recommendations are based on limited or inconsistent scientific evidenceevidence (Level B):(Level B): Women with vertical incision with the lower uterine segment that does not extend into the fundus are Women with vertical incision with the lower uterine segment that does not extend into the fundus are

candidates for VBAC.candidates for VBAC. The use of prostaglandins for cervical ripening or induction of labor in most women with a previous The use of prostaglandins for cervical ripening or induction of labor in most women with a previous

cesarean delivery should be discouraged.cesarean delivery should be discouraged.

The following recommendations are based primarily on consensus and expert opinion (Level C):The following recommendations are based primarily on consensus and expert opinion (Level C): Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped 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.to respond to emergencies with physicians immediately available to provide emergency care. After thorough counseling that weighs the individuals benefits and risks of VBAC, the ultimate decision After thorough counseling that weighs the individuals benefits and risks of VBAC, the ultimate decision

to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.physician. This discussion should be documented in the medical record.

Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or extensive transfundal uterine surgery.uterine incision or extensive transfundal uterine surgery.

ACOG Practice Bulletin N. 54. July 2004. Vaginal Birth After Previous Cesarean Delivery.ACOG Practice Bulletin N. 54. July 2004. Vaginal Birth After Previous Cesarean Delivery.

Optimum TOLACOptimum TOLAC

1.1. One prior low transverse scar.One prior low transverse scar.

2.2. Clinically adequate pelvis.Clinically adequate pelvis.

3.3. High Bishop Score.High Bishop Score.

4.4. Prior NSVD.Prior NSVD.

5.5. Prior VBAC.Prior VBAC.

6.6. BMI <30 kg/mBMI <30 kg/m²²

7.7. Fetal monitoring.Fetal monitoring.

8.8. Induction of labor, only with prior NSVD.Induction of labor, only with prior NSVD.

9.9. Interdelivery interval of >18 months.Interdelivery interval of >18 months.

10.10. Double layer closure on uterus?Double layer closure on uterus?

11.11. Lower uterine segment > 3.5 mm. Lower uterine segment > 3.5 mm.

12.12. Immediate availability of OR, anesthesiologist, and obstetrician.Immediate availability of OR, anesthesiologist, and obstetrician.

13.13. Informed consent.Informed consent.

To TOLAC or Not to TOLAC?To TOLAC or Not to TOLAC?That is the Question!That is the Question!

∼ ∼ Howard Blanchette, M.D.Howard Blanchette, M.D.