Practice bulletin. Candidates for VBAC: 1 or 2 prior LTCS, clinically adeq. pelvis, No other uterine scars or prev. rupture, Physician readily available throughout labor capable of monitoring labor and performing an emergency CS, availability of anesthesia dn OR personnel for emergency delivery. Success: overall 60-80% success but population dependent. There is no reliable scoring system to predict success. PCS for nonrecurring reasons have similar success to pts with no PCS. Approx. 50-70% of pts with dystocia are successful. Risk/Benefit: Neither VBAC nor ERCS are without risks. It is difficult to calculate cost/benefit for VBAC. Most recent studies have shown that the women attempting VBAC are at greater risk for major maternal morbidity: UR, hysterectomy and operative injury. UR can be a life threatening for both mother and infant. When catastrophic UR occurs, some patients will require hysterectomy and some infants will die or will be neurologically impaired. In most cases, the cause of UR is unknown but poor outcomes can result even in appropriate candidates. Estimated occurrence of UR is 4-9% with a classical or a "T" incision, 1-7% with a LVCS and 0.2-1.5% with a LTCS. The most common sign of UR is a nonreassuring FHT pattern with variable decelerations that may evolve into late decelerations. Other Sx are more variable and include pain, loss of station, vaginal bleeding and hypovolemia. Contraindications: Prior classical or T shaped incision, contracted pelvis, inability to perform immediate emergency CS because of unavailable surgeon, anesthesia, staff or facilities. Anesthesia: VBAC is not a contraindication to epidural anesthesia and adequate pain relief may encourage mor women to choose TOL. Epidural rarely masks the signs and symptoms of UR. Intrapartum Management: Pt evaluated promptly once labor has begun, usually use fetal monitor. Personnel familiar with the potential complications of VBAC should be present to watch for nonreassuring FHT patterns and inadequate progress in labor. Induction: Induction or augmentation has been suspected as a factor in UR. A meta-analysis found no relationship between the use of Pitocin and UR. There are occasional reports of UR with prostaglandin preparations. Summary: Level A confidence: 1. Most can be offered a TOL. 2. Epidural may be used. 3. Previous uterine incision extending into the fundus is a contraindication. Level B confidence: 1.
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