6/5/05njm

**Q**. **What kind of surgical availability is necessary for vaginal
birth after cesarean (V.B.A.C.)?**

**A.**
[V.B.A.C.](http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/VBAC6504.doc)
should be attempted in institutions equipped to respond with physicians
immediately available to provide emergency delivery.

ACOG states

"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." (Practice Bulletin
NUMBER 54, JULY 2004)

What does 'immediately' available mean?

The meaning of 'immediately' available should be determined locally.

Do all providers need to be 'in house'?

Do all appropriate operating room staff need to be on site throughout a
VBAC labor?

Does the infant care provider need to be onsite?

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PedEmerDel5705.doc>

According to Leung 1993 in situations of bradycardia with uterine
rupture, delivery is best accomplished within 17 minutes of the onset of
severe bradycardia. Please read below some strategies on how to approach
this issue for your facility.

**Background**

Between 1970 and 1988, the cesarean delivery rate in the United States
increased dramatically from 5% to nearly 25%. The rapid growth was
likely a result of increased pressure that discouraged physicians from
performing vaginal breech deliveries and midpelvic forceps deliveries.
At the same time, increasing reliance on continuous electronic
monitoring of fetal heart rate and uterine contraction patterns led to
an increase in the number of cesarean deliveries performed for presumed
fetal compromise and dystocia, respectively. With few exceptions, major
improvements in newborn outcomes as a result of the increased cesarean
delivery rate are yet to be proved).

**What are the risks and benefits associated with VBAC?**

Neither elective repeat cesarean delivery nor VBAC is without risk.
Generally, successful VBAC is associated with shorter maternal
hospitalizations, less blood loss and fewer transfusions, fewer
infections, and fewer thromboembolic events than cesarean delivery.
However, a failed trial of labor may be associated with major maternal
complications, such as uterine rupture, hysterectomy, and operative
injury, as well as increased maternal infection and the need for
transfusion. Neonatal morbidity also is increased with a failed trial of
labor, as evidenced by the increased incidence of arterial umbilical
cord blood gas pH levels below 7, 5-minute Apgar scores below 7, and
infection. However, multiple cesarean deliveries also carry maternal
risks, including an increased risk of placenta previa and accreta. Based
on these risks, one decision model analysis found it is reasonable to
consider a trial of labor if the chance of success is 50% or greater,
and the desire for future pregnancy after cesarean delivery is at least
10--20%.

The incidence of maternal death with VBAC is extremely low. In a recent
meta-analysis, only 3 maternal deaths were reported among the more than
27,000 women who attempted a trial of labor after a prior cesarean
delivery. Although the incidence of perinatal death is low (generally
less than 1%), it is more likely to occur during a trial of labor than
an elective repeat cesarean delivery. Uterine rupture has been
associated with fetal death, as well as severe neonatal neurologic
injury.

Uterine rupture during a trial of labor after a previous cesarean
delivery is a life-threatening complication that has been directly
attributed to attempted VBAC. In most cases, the cause of uterine
rupture is unknown, but poor obstetric outcomes can result even in women
who are appropriate candidates for VBAC. The exact incidence of uterine
rupture is difficult to determine because reports in the literature have
sometimes grouped true, catastrophic uterine ruptures together with
asymptomatic scar dehiscences. Additionally, early case series included
ruptures in the absence of labor as well as ruptures during labor in
women with previous classical incisions. The rate of uterine rupture is
largely dependent on the type and location of the previous incision.
Uterine rupture rates in women with previous classical incisions and
T-shaped incisions range between 4% and 9%. Although uterine rupture
occurs more often in women undergoing a trial of labor than women who
elect repeat cesarean delivery, rupture rates during attempted VBAC
generally are less than 1%.

The risk of uterine rupture also is influenced by obstetric history. A
previous vaginal birth significantly reduces the risk of uterine
rupture. The risk of uterine rupture appears to be inversely related to
the length of time between deliveries, ie, the longer the interval
between deliveries, the lower the risk of rupture. Women who attempt
VBAC who have interdelivery intervals of less than 24 months have a
2--3-fold increased risk of uterine rupture when compared with women who
attempt VBAC more than 24 months after their last delivery. Finally, the
findings of one nonrandomized trial suggest that compared with a double
layer closure, a single layer closure of the hysterotomy incision in the
primary cesarean delivery may increase the risk of uterine rupture
4-fold during a subsequent trial of labor.

Common signs of uterine rupture are a nonreassuring fetal heart rate
pattern with decelerations or bradycardia. Other findings are more
variable and include uterine or abdominal pain, loss of station of the
presenting part, vaginal bleeding, and hypovolemia.

**What are contraindications for VBAC?**

A trial of labor is not recommended in patients at high risk for uterine
rupture. Circumstances under which a trial of labor should not be
attempted are as follows:

-   Previous classical or T-shaped incision or extensive transfundal
    uterine surgery

-   Previous uterine rupture

-   Medical or obstetric complication that precludes vaginal delivery

-   Inability to perform emergency cesarean delivery because of
    unavailable surgeon, anesthesia, sufficient staff, or facility

-   Two prior uterine scars and no vaginal deliveries

In addition, a combination of factors that would not ordinarily
constitute a compelling case to proceed with a primary cesarean delivery
might be considered sufficient to choose repeat cesarean delivery
instead of VBAC in some situations.

Here are some factors associated with various risk levels

**Low**

Spontaneous labor

One previous cesarean delivery

Normal tracing

**Medium**

2 previous cesarean deliveries

Augmentation of labor

Induction of labor

\< 18 month interval

**High**

Abnormal fetal heart rate pattern, not resolving

No change in labor despite adequate contractions

Vaginal bleeding, like an abruptio

[VBAC: Is There Such a Thing as Low
Risk?](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt)

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt>

**What can a facility do to prepare for a catastrophic uterine
rupture?**

I suggest you look at it another way....as catastrophic uterine rupture
is rare, how well is your facility prepared for any emergency delivery?
e.g., shoulder dystocia, etc...

I submit your facility should perform regular periodic emergency
delivery drills, regardless of your choice to provide VBAC. Here is a
resource that outlines the many advantages of drills for the whole labor
and delivery system:

[Emergency Delivery Simulations: How to Develop
Teamwork](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt)

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/Talk.ppt>

**Summary**

The risk of catastrophic uterine rupture is rare. According to Leung
1993 in situations of bradycardia with uterine rupture, delivery is best
accomplished within 17 minutes of the onset of severe bradycardia.

Your facility should be prepared for an emergency delivery, regardless
of the etiology. Once your facility has performed a number of adequate
emergency delivery drills, you will be much better to determine what
'immediately available' surgical capacity means at your facility.

**Other related FAQs**

**Q.** **How does birth interval affect the repeat cesarean vs vaginal
delivery decision?**

**A.** Intervals \< 18-24 months [slightly increase
risk](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/cesInterv122604.doc),
but it is something the patient can control.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/cesInterv122604.doc>

**Q.** **What are some of the issues involving rapid cesarean delivery +
local anesthesia?**

**A.** It can be quite uncomfortable despite local infiltration

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/RapCes111404.doc>

**Q.** **Do all hospitals need cesarean delivery capacity?**

**A.** Here is an [example in which careful
triage](http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/CesAvail6504.doc)
leads to excellent outcomes.

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/CesAvail6504.doc>

**Q.** **Does there have to be Pediatrician at all emergency
deliveries?**

**A.** The standard is a healthcare worker experienced in neonatal
resuscitation.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PedEmerDel5705.doc>

**References:**

**Vaginal Birth After Previous Cesarean Delivery**

**ACOG Practice Bulletin** NUMBER 54, JULY 2004

ACOG Members

<http://www.acog.org/publications/educational_bulletins/pb054.cfm>

Non-ACOG Members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15229039&query_hl=12>

**Vaginal birth after cesarean delivery: UpToDate**

<http://www.uptodateonline.com/application/topic.asp?file=labordel/9085&type=A&selectedTitle=1~6>

**Cesarean delivery: UpToDate**

<http://www.uptodateonline.com/application/topic.asp?file=labordel/6548>

**Patient information: Vaginal birth after cesarean delivery (VBAC):
UpToDate**

<http://www.uptodateonline.com/application/topic.asp?file=pregnan/6563&type=A&selectedTitle=3~6>

Leung AS, et al. Risk factors associated with uterine rupture during
trial of labor after cesarean delivery: A case-control study. Am J
Obstet Gynecol 1993; 168:1358-63.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8498412&query_hl=3>

**Vaginal Birth After Cesarean delivery: CME module, Indian Health**

<http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm>