GYN.COM PRESENTS

LIFE LONG WOMEN'S HEALTH CARE

ERIK N. COHEN, M.D. AND ASSOCIATES

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ERIK N. COHEN, M.D. AND ASSOCIATES

VAGINAL BIRTH AFTER CAESARIAN

VBAC

Perhaps one of the more difficult decisions for both the patient and the physician to make is whether to proceed with an attempted vaginal birth after caesarian section. There is not one correct answer, but rather risk assessment on both the patient's mind and that of her physician.  Thousands of pages of information are available for review, and are beyond the scope of GYN.COM.  Rather,  a short review of the benefits and risks of an attempted VBAC will be summarized as a focus point for our patients to discuss the issue with us.

 

Ever since the beginning of the medical era of abdominal delivery which began  in 1881 by Ferninand Adolph Kehrer in Germany the integrity of the scar in the uterine wall has been questioned. It is reported that the depending on the incision made the first time, 4% of the vertical incisions may rupture. and as low as .07% in low transverse scars.

 

The American College of Obstetricians and Gynecologists continue to change their recommendations. They state that it is the patient after counseling who makes the final decision and that no woman should be forced to undergo a trial of labor with a previous uterine scar. It is clear that the facility must have the resources to perform an immediate emergency caesarian in the event of a catastrophic rupture of the uterus.  Even with this ability the patient must be aware of the risk to not only herself of bleeding and death but also of the risk of serious or even fatal injury to her child.

 

Candidates for a trial of labor based on case reports include those with a single low-transverse uterine incision from a previous caesarian section.  Increased risk is present for those with two prior caesarians, but after being informed of the increased risk may also be candidates. Twin gestations may also be considered though evidence suggests a doubling of the risk of uterine rupture. Though evidence may suggest a slightly higher risk to the baby in vaginal breech deliveries, this adds even more to the decision to permit a trial of labor. Even a suspected large infant on its own does not contraindicate the attempt at a vaginal birth.

Patients who are at high risk for uterine rupture and thus should not attempt a VBAC include those with a previous classical or "T" shaped incision, small pelvis, and medical or obstetrical conditions that would generally indicate a caesarian section. If the facility where the patient wishes to deliver is insufficiently staffed, or is without adequate emergency facilities including laboratory, blood bank or anesthesia availability VBAC should not be attempted.

 

Induction of labor  during an attempted VBAC also remains contraversial. Induction with Prostaglandin E2 gel may be attempted, though case reports of uterine rupture have occurred.  Misoprostol another drug used often to induce labor, has been found to increase the rate of uterine ruptures in the presence of a previous scar, and now is recommended by ACOG to NOT be used. Pitocin (oxytocin) is considered safe.

 

Sample Consent Form

Erik N. Cohen, M.D. and Associates

9360 No Name Uno, Suite 230

Gilroy, Ca. 95020

(408) 848-2100

 

VAGINAL BIRTH AFTER CESAREAN SECTION PATIENT CONSENT FORM

NOTE TO PATIENT: As you may know, there are risks in any medical, surgical procedure or treatment. Just being pregnant carries some risks, as there are risks in everyday activities such as driving. The following check list is designed to help you to make an informed decision as to whether you decide to attempt to deliver "normally" after you had a prior cesarean section. This procedure medically is called a Vaginal Birth After Caesarian section and is abbreviated "VBAC". Your other option is to have a repeat cesarean section. Please discuss the contents of this form with your physician, initial off on each section and choose your option of attempting a VBAC or a repeat cesarean section to deliver your baby.

 

Patient's Initials

  1. I understand that I have had one or more prior cesarean(s).

__________

  1. I understand that I have the option of an elective repeat cesarean or to attempt a vaginal birth after a cesarean (VBAC).

__________

  1. I understand that approximately 70% of women who undergo a VBAC will successfully deliver vaginally.

__________

  1. I understand that VBAC may carry a lower risk to me than a cesarean delivery. The benefits of a successful VBAC include decreased blood loss, decreased post delivery complications and a shorter recuperative period.

__________

  1. I understand that the risk of a uterine rupture during VBAC in someone like me who has had a prior incision in the non-contracting part of my uterus is at least 1%.

__________

  1. I understand that VBAC is associated with a higher risk of harm to my baby than to me.

__________

  1. If my uterus ruptures during my VBAC, I understand there may not be sufficient time to operate and prevent death or permanent brain injury to my baby.

__________

  1. The exact frequency of death or permanent neurological injury to the baby when the uterus ruptures is uncertain, but has been reported to be as high as 50%.

__________

  1. The risks to me after rupture of the uterus include but are not limited to hysterectomy (loss of the uterus), blood transfusion, infection, injury to internal organs , (bowel, bladder, ureter), blood coagulation problems or death.

__________

  1. Probable contraindications to VBAC include previous classical uterine incision, multiple gestations and breech.

__________

  1. Also excluded from considerations for VBAC are patients unwilling to assume the added risks associated with a trial of labor for themselves and their baby.

__________

  1. I understand that during my VBAC, the use of oxytocin (Pitocin), a hormone, to make my uterus contract, may be necessary to assist me in my vaginal delivery. There may be increased risk with the use of oxytocin during VBAC.

__________

  1. I understand that if I choose a VBAC and end up having a cesarean during labor, I have a greater risk of problems than if I had an elective repeat cesarean.

__________

  1. I have read or have had read to me the above information and I understand it. I have had all of  my questions answered and I have received all the information I need to make an informed choice, after discussing my options with my Doctor.

__________

 

I want to attempt a VBAC

_____________________________

_____________________________

OR

(Patient's Signature)

(Date)                              (Time)

I want a repeat cesarean

_____________________________

_____________________________

 

(Patient's Signature)

(Date)                              (Time)

Patient Printed Name:

_____________________________

 

 

Witness: _____________________________

_____________________________

________________

(Signature)

(Print Name)

(Date)

 

 

 


LINKS TO VISIT

http://www.physweekly.com/archive/01/11_05_01/pc.html

http://www.worldserver.com/turk/birthing/VBACRiskMitigation.html

http://www.gentlebirth.org/archives/icanvbac.html

 

 
 

 

Copyright © 2001 Erik N. Cohen M.D. and Associates
Last modified: June 20, 2002