Vaginal Birth After Cesarean questions

JoniL&DRN · Oct 12, 2004

Hi Mandy and welcome to the list.. you might want to move this thread to the Labor and Delivery section. You'd probably have better luck there. Sorry I have no sound advice to offer... I am a student myself.

I do have several friends though who have attempted VBAC, some successful some not. Mostly seemed dependent on the reason for the first C-Sec. Was it fetal distress or some other emergency or failure to progress? The women who have a failure to progress seem to be less sucessful in VBAC than those who had an emergency situation. Our small town hospital doesn't encouage VBAC very often.. too afraid of malpractice I would venture to guess. Best of luck to your in your research.

imenid37 · Oct 12, 2004

Hi Mandy,

Welcome to nursing. I hope you have a great semester. I think VBAC is now discouraged by some physicians and hospitals because of liability issues. Here in PA, medical liability is a HUGE issue. I work in a smal community hospital w/ about 60 deliveries/month. We do not have anesthesia, peds, or ob in house 24/7. Patients wishing to have a VBAC must view a video in the office (for the larger practice who serves our hospital) and sign a special waiver that they have recieved information on the risks of VBAC and still wish to proceed. Once they see the video, a lot change their minds. The other physician practice, a solo practitioner, doesn't offer VBAC anymore. A pt. having a VBAC is one on one care in labour. They won't use gel to ripen her cervix and do not like to use pit. We have had a number of patients who present in spontaneous labour who will go for VBAC if they are in advanced labour and progressing well. We have had other pt's present at 5-6 cm or more and because of extreme fear, insist on a C/S. We did have one uterine rupture w/ a patient on pit several years ago on a Saturday a.m. The OR was in house, but had not yet started their orthopedic case which was bumped for the stat C/S. The baby was born and did very well. Mom also did well. Many larger hospitals will tell that a smaller place such as ours should not do VBAC's.

Here's an ACOG blurb on VBAC. Try their website for more info. Your patient can try it too, so she will be well-informed. http://www.acog.org and also awhonn.org

When Planning for lady partsl Delivery May Not Be Appropriate

Both Dr. Lockwood and Michael F. Greene, MD, director of maternal-fetal medicine at Massachusetts General Hospital in Boston, cited recent warnings that labor inductions using prostaglandins carry risks for patients with prior uterine scars and cesarean delivery who are attempting a lady partsl delivery. "Recent reports in the New England Journal of Medicine suggest that all prostaglandins used to induce labor in women with prior cesarean deliveries could increase the risk of infant mortality," reported Dr. Greene.

Dr. Greene addressed the US rate of cesarean deliveries, which rose from a rate of 5.5 percent of all births in 1970, to a high of 24.7 percent of births in 1988. The rate began to drop in the years 1989 to 1997, following medical efforts to promote lady partsl Birth After Cesarean (VBAC) delivery. But the rate rose again to 22 percent in 1999, following case reports of increased incidence of uterine rupture in women attempting VBAC.

"A recent report of a large, population-based observational study has found that spontaneous labor after a prior c-section is associated with a tripling of the risk of uterine rupture compared to elective repeat cesarean delivery," said Dr. Greene. "In such cases, labor induction with a prostaglandin increases the risk of uterine rupture 15-fold, to a rate of 24.5 uterine rupture cases per 1,000 women. And the incidence of infant death is 10 times higher among women who experience uterine rupture," warned Dr. Greene.

"Some may conclude that the absolute risks for these events are small, but women making an attempt at lady partsl delivery following cesarean must make an informed decision on this," noted Dr. Greene.

Dr. Greene announced ACOG's new Committee Opinion, Mode of Term Singleton Breech Delivery, which cautions against the use of a planned lady partsl delivery in most cases of breech presentation (when the fetus is not in a head-first position prior to delivery). ACOG is now recommending that obstetricians continue to reduce the chance of a breech birth by attempting external cephalic version (attempts to manually turn the fetus in the uterus), but that if such efforts are not successful, a planned lady partsl delivery is not appropriate.

"An exceptionally large clinical trial found that perinatal and neonatal mortality and morbidity were significantly lower using a planned cesarean rather than a lady partsl delivery in these breech cases," reported Dr. Greene. "And there was no increase in the rates of maternal morbidity and mortality in women undergoing cesarean delivery in these cases. "

Also try this link for an article on meting the demand for VBAC in the face of incresing liability. http://www.acog.org/from_home/publications/press_releases/nr05-02-04.cfm

Best of luck to you and your patient! :)

prmenrs, RN · Oct 12, 2004

I am moving this thread to OB-GYN as you may get more response there.

bam_bam · Oct 12, 2004

At my institution we don't encourage or discourage. Our patients are presented with the risks/benefits and make there own decision. They have to sign a VBAC consent form to attempt a VBAC. I personally am a VBAC proponent. I don't believe the risks have increased with VBACs but that providers were very complacent. They treated VBACs the same as any other labor. Using pitocin and prostaglandins at will.

hoolahan, ASN, RN · Oct 12, 2004

I can only speak as a mom (and a non-OB nurse) who had both. My first C-sec was a low transverse incision.

No one discouraged me, but I went to a midwife, so I was encouraged. I had also read the book Silent Knife, for lay people, which was very eye-opening regarding the number of unecessary C-sections done in the US.

I had absolutely no problem. My labor was fairly easy, and I felt sooooo much better and able to take care of the baby after the lady partsl. I had a very very bad expereince with the C-section, and I just didn't want to put myself through it again.

That was 15 years ago, and to date, I have not had any long-term complications from it.

Good luck with your studies Mandy. You presented yourself so well, and professionally. Nice to see you are taking evidence-based nursing practice to heart. I predict you will be very successful in your career.

fergus51 · Oct 12, 2004

I think the practice is more accepted in Canada than in the US. Here doctors seem much more concerned about liability, especially since that lame study got so much hype. It's the use of inducing agents that increases the risk of rupture so much.

And I have to agree, your post is great! Nice to see a student who puts time into researching things!

Long Term Care Columnist / Guide · Oct 13, 2004

I had a VBAC after 2 cesareans, and couldn't have been happier with either my decision or the doctor who encouraged me to try. Several other OBs had told me to forget it, because I was very heavy and my babies tended to be large as well; but this one young doctor believed I could do it, and thankfully he was on duty the day I went into labor. I gave birth without so much as a Tylenol for pain, was able to hold and feed my 8-pound 2-ounce son almost immediately, and was walking around the floor 2 hours after delivery......what a difference!!

That was 16 years ago this Friday. How sad, that this same facility where I had the best birth experience of my life now no longer offers VBAC as an option.

PegRNBSN · Oct 13, 2004

We also don't encourage or discourage but the physician presents the facts, hopefully early in the pregnancy so dialog and plans can be made well ahead of labor. We have our patients sign a VBAC consent form that states their intentions either way (opting for a VBAC trial or repeat c-section).

I have been involved in several uterine ruptures with VBAC attempts. They have reemphasized the importance of strong surveillance of these moms and the high risk nature of these labors. The potential for uterine rupture is the reason that VBACs should only be attempted at a hospital that has in house staff to insure that a c-section can be done within minutes. Mom should always have IV access.

I personally had two VBACs after a low transverse c-section. I had no problems.

naggytabby, BSN, RN · Oct 13, 2004

Mandy,

You might also want to visit http://www.midwife.org. That's the ACNM site and they have info on VBAC, maybe with a slightly different slant than ACOG. You can also peruse http://www.midwiferytoday.com.

Enjoy!

Elenaster · Oct 13, 2004

Mandy,

From a non-OB nurse, but someone who spent a good deal of time researching VBACs this year, these websites have alot of info:

http://www.ican-online.org/

http://www.vbac.com/

Good luck!

SmilingBluEyes · Oct 13, 2004

You have received excellent advice. Be sure you research it thoroughly and decide if it's for you. Then make your wishes clear to your health care providers. Be aware of the benefits and potential risks of ANY procedure involved in giving birth, including repeat csection; arming yourself with knowledge is a powerful thing! I wish you a safe, happy delivery and baby!