ACOG PRACTICE BULLETIN #115 PDF

View all sections in the guide, including a link to the authors, on the index page. Vaginal births after prior cesareans VBAC s were not always as uncommon as they are now. In , three years after a widely publicized but also widely criticized study was published MacMahon et al. These recommendations were given a Level C rating, which means they were based on consensus and expert opinion, not research.

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Related Editorial. Advantages of this approach include avoidance of major surgery, lower risk of hemorrhage and infection, and shorter recovery periods.

Between and , rates of vaginal birth after previous cesarean delivery VBAC increased steadily. Since the mids, however, medicolegal issues and concerns about the risk of uterine rupture have contributed to a reversal in this trend.

Although a trial of labor after previous cesarean delivery TOLAC is appropriate in select women, several factors increase the likelihood of complications.

The risks associated with TOLAC are the same as those associated with elective repeat cesarean delivery: maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. The outcome of TOLAC that most significantly increases the risk of maternal and neonatal morbidity is uterine rupture or dehiscence. The incidence of uterine rupture varies, but the risk is higher in women with a history of hysterotomies. The location of the prior uterine incision influences risk.

Individual demographic and obstetric factors that affect a woman's probability of successful TOLAC are listed in Table 1. Decisions about TOLAC should take into account the possibility of future pregnancies, because delivery decisions made in the first pregnancy after a cesarean delivery typically affect plans in subsequent pregnancies.

Because of the risks associated with TOLAC, it should be attempted in facilities with staff immediately available to provide emergency care. Adapted with permission from American College of Obstetricians and Gynecologists. ACOG practice bulletin no.

Vaginal birth after previous cesarean delivery. Obstet Gynecol. Women at high risk of complications e. The safety of VBAC has been questioned in women who had a previous cesarean delivery with an unknown incision type. However, two case series reported similar rates of successful VBAC between women with unknown previous incision types and those with previous low transverse incisions.

No significant association was noted between unknown incision types and rates of uterine rupture. Therefore, TOLAC is not contraindicated in women who have had one previous cesarean delivery with an unknown incision type, unless there is high clinical suspicion of a previous classical incision.

It is unclear whether the risk of uterine rupture is lower in women attempting TOLAC who have had only one previous cesarean delivery compared with those who have had more. The chances of achieving VBAC are similar between these groups of women.

Therefore, it is reasonable to consider TOLAC in women who have had two previous low transverse cesarean deliveries, and to counsel them based on other factors that affect their chances of successful VBAC.

Data on the risk in women who have had more than two previous cesarean deliveries are limited. Women attempting TOLAC with a macrosomic fetus greater than 4, to 4, g [8 lb, 13 oz to 9 lb, 15 oz] have a lower likelihood of successful VBAC than those who have a nonmacrosomic fetus.

Women who have had a previous cesarean delivery because of dystocia also have a lower likelihood of VBAC if the weight of the current fetus is greater than that of the index pregnancy. There is limited evidence that the risk of uterine rupture is greater in women who have not had a previous vaginal delivery and who are attempting TOLAC with a macrosomic fetus.

It is important to note, however, that these data are based on actual—not predicted—birth weight, thus limiting their applicability when making delivery decisions antenatally.

Although previous and predicted birth weights should be considered when making delivery decisions, suspected macrosomia alone is not a contraindication for TOLAC. However, most studies have not shown that the risk of uterine rupture is increased in these women.

Women with twin gestations who attempt VBAC have similar outcomes to women with singleton gestations. Therefore, TOLAC can be considered in women who have had one previous cesarean delivery with a low transverse incision and who have no contraindications for twin vaginal delivery. Several studies have noted an increased risk of uterine rupture after labor induction in women attempting TOLAC.

Although labor can be induced for maternal or fetal indications in women attempting TOLAC, physicians should counsel the patient that it increases risk of uterine rupture and decreases the possibility of successful VBAC. Studies of the effects of prostaglandins on uterine rupture in women who have had a previous cesarean delivery have had inconsistent results. One large study found an increased risk of uterine rupture, whereas a second study found no increased risk, and a third found no increased risk when prostaglandins were used alone with no subsequent oxytocin [Pitocin].

Studies of specific prostaglandins are limited, but generally indicate that the risk of uterine rupture may vary among agents. Evidence from small studies shows that the use of misoprostol Cytotec increases the risk of uterine rupture in women who have had previous cesarean deliveries.

Therefore, this agent should not be used for third trimester cervical ripening or labor induction in women who have had a previous cesarean delivery or major uterine surgery.

Limited data suggest that external cephalic version for breech presentation is not contraindicated in women with prior uterine incisions if the risk of adverse maternal and neonatal outcomes is low.

The chances of successful external version are similar in women with and without a previous cesarean delivery. Effective regional analgesia should not be expected to mask signs of uterine rupture. Already a member or subscriber? Log in. Many hospitals no longer allow VBAC because they are not able to provide immediate access to surgeons and anesthesiologists, and some insurance carriers prohibit physicians from performing the procedure.

National Institutes of Health Consensus Development Conference statement: vaginal birth after cesarean: new insights. March 8—10, Scott JR. Solving the vaginal birth after cesarean dilemma [editorial]. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes.

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Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Next: Intestinal Obstruction. Jan 15, Issue. Yes Evidence rating system used? Factors Associated with Successful Trial of Labor After Previous Cesarean Delivery Increased probability of success Previous vaginal birth Spontaneous labor Decreased probability of success Gestational age greater than 40 weeks Increased maternal age Increased neonatal birth weight Maternal obesity Nonwhite ethnicity Preeclampsia Recurrent indication for cesarean delivery Short interpregnancy interval Adapted with permission from American College of Obstetricians and Gynecologists.

Table 1. Read the full article. Get immediate access, anytime, anywhere. Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue. Purchase Access: See My Options close. Best Value! To see the full article, log in or purchase access. Are you sure? More in Pubmed Citation Related Articles. Email Alerts Don't miss a single issue. Sign up for the free AFP email table of contents. Navigate this Article. Literature search described? Evidence rating system used?

Increased probability of success. Previous vaginal birth. Decreased probability of success. Gestational age greater than 40 weeks. Increased maternal age. Increased neonatal birth weight. Recurrent indication for cesarean delivery. Short interpregnancy interval.

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ACOG Updates Recommendations on Vaginal Birth After Previous Cesarean Delivery

Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: In addition to fulfilling a patient's preference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. View on PubMed. Save to Library. Create Alert.

AKUPRESURA RECEPTORY PDF

The "Immediately Available" Standard for VBAC

Related Editorial. Advantages of this approach include avoidance of major surgery, lower risk of hemorrhage and infection, and shorter recovery periods. Between and , rates of vaginal birth after previous cesarean delivery VBAC increased steadily. Since the mids, however, medicolegal issues and concerns about the risk of uterine rupture have contributed to a reversal in this trend. Although a trial of labor after previous cesarean delivery TOLAC is appropriate in select women, several factors increase the likelihood of complications. The risks associated with TOLAC are the same as those associated with elective repeat cesarean delivery: maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death.

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ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery.

In addition to fulfilling a patient's preference for vaginal delivery, at an individual level VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies. At a population level, VBAC also is associated with a decrease in the overall cesarean delivery rate 1, 2. Although TOLAC is appropriate for many women with a history of a cesarean delivery, several factors increase the likelihood of a failed trial of labor, which compared with VBAC, is associated with increased maternal and perinatal morbidity The purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and provide practical guidelines for managing and counseling patients who will give birth after a previous cesarean delivery. This site needs JavaScript to work properly. Please enable it to take advantage of the complete set of features!

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