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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Vaginal Birth After Cesarean
Sponsored by The Indian Health Service Clinical Support Center
11. Summary of Recommendations
Summary
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. After thorough counseling that weighs the individual 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 physician. This discussion should be documented in the medical record.
The Northern New England Perinatal Quality Improvement Network presents TOLAC Risk factors to help guide discussions with your patient as they make an informed decision about the mode of delivery.
It would seem that women with one prior lower-segment transverse cesarean may safely be offered the option of T.O.L.A.C. with the precautions mentioned.
If these conditions--electronic fetal monitoring, blood banking, and surgical and anesthesia providers--cannot be offered on site, the patient should be expeditiously transported to the appropriate facility. Remember, the goal is not a vaginal birth, the goal is a healthy mom and baby!
Last but not least, your institution should perform periodic drills to assure that you can respond all obstetric emergencies in a timely and efficient manner.
Indian Country experience
While there has not been a study of VBAC, per se, in Indian Country there is data about intentional triage systems with demonstrated success.
Leeman and Leeman # 1 reports the presence of a rural maternity care unit without surgical facilities can safely allow a high proportion of women to give birth closer to their communities. Their study demonstrated a low level of perinatal risk. Most transfers were made for induction or augmentation of labor. Rural hospitals that do not have cesarean delivery capability but are part of an integrated perinatal system can safely offer obstetric services by using appropriate antepartum and intrapartum screening criteria for obstetric risk.
Leeman and Leeman # 2
reports on a primarily Native community's low rate of cesarean delivery is primarily the result of a decreased use of cesarean delivery for labor dystocia and an almost universal acceptance of trial of labor after cesarean delivery. Cultural attitudes toward childbirth, design of the perinatal system, and genetic factors also may explain the low rate of cesarean delivery.
Mahoney and Malcoe report that despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations.
Clearly, careful regionalization of care for Native patients to appropriate care settings is a successful model.
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