Specialties Ob/Gyn


Recently we had a ruptured uterus after receiving small doses of Pit during a trial of labor. How often do you attempt VBAC's and what is your policy on pit usage for a previously scarred uterus?

At our hospital (over 450 deliveries a month), we try to VBAC most of our prev. C/S. Most of our doc's do like an IUP placed as soon as possible. Our perinatologists are presently doing some research into what makes for a more successful VBAC candidate and are doing strip reviews. Look for more updates soon.

We too had a recent ruptured uterus during VBAC induction of labor. It was a very bad outcome. The infant died and the mother sustained massive trauma to the uterus with a large EBL. Currently we do not have in our policy for all VBAC's to have IUPC's. Today I labored a VBAC without a IUPC with frequent variables and some lates however maintained good variability throughout and had a very successful VBAC without an IUPC. However I was very cautious with the Pit and I'm sure after the ruptured uterus many of our staff with be cautious with the pit also. I feel many of our nurses have lost the ability to assess a contracting uterus with palpation and rely too much on the toco.

We have had several successful VBAC's with and without pit. I remember when we first started VBAC TOL they weren't allow to have labor epidurals because it would mask any symptoms of uterine rupture. Now they can have labor epidurals and before the rupture I think many of the nurses are very lax and not worried about rupture. I have seen some windows in some of my failed VBAC's and that always would humble me to respect the previous scarred uterus.

the doctor i work with uses the following criteria: patient must have bikini incision, reason for previous section must be other than cephalo-pelvic disproportion and must be monitored very closely for i.e, contractions , fetal response etc.

We encourage patients to try a VBAC. Our policy is that Pitocin can NOT be used for induction of VBAC's but can be used with labor augmentation. The previous uterine incision must also be low transverse.

Specializes in L&D, NICU, PICU, School, Home care.

We no longer do VBACs. We do not have in house OR crew or anesthesia 24/7 so too dangerous.

we do attempt vbacs, but most of the nurses and docs would rather not. there is one group of docs that work with midwives and they do the most vbacs. we have had a couple of uterine ruptures most with good outcomes, but for me personally i don't like taking care of most vbacs unless the are doing it without any pitocin.

We no longer do VBACs. We do not have in house OR crew or anesthesia 24/7 so too dangerous.

Here's my question - to anyone who might want to answer. How do hospitals who don't do VBACs because they feel lacking 24-hr OB or anethesiology coverage makes VBACs too unsafe due to inability to perform a stat c/s for a rupture handle other OB emergencies? What about a cord prolapse or a baby whose FHTs crash and don't recover? These things are just as likely to occur (looking at the statistics) as a rupture in an appropriately managed VBAC candidate.

Just curious what others think.

Specializes in L&D, NICU, PICU, School, Home care.

We have a decision to incision rule of 30 min. Both OR crew and anesthesia are available on call. We open the OR and start as long as there is a scub here (we are lucky that 2 live within 5 min. and are willing to come in for a stat to cover until scheduled on call arrive). We pray that we never have one that needs faster. We recenlty had a mom who was GD who was in for a amnio for lung maturity. She spoke no english and said nothing about "dolor" when asked. She had that "look" on her face and was 8cm. Her water broke during the exam and the cord prolapsed. We had baby out in 15 min. Talk about a scarey event. Poor woman spoke no English and her interpreter was with another pt. Her last baby was stillborn history said Large baby home birth in rural no where. She must have been terrified with one nurse no taking her hand out and the rest of poking her with needles. Great outcome with mother and baby doing fine.

The facility that I used to work at attended VBACs if a low incision had been made, and if good healing had occurred (for example, if mom was treated for a uterine infection post-vbac, we would not attend the VBAC). Absolutely no induction or augmentation of labor with VBACs. Otherwise everything as usual. No ability to do c-sections (it was a birth center, we had to transport for complications that required surgical birth).

The facility I work at now has a no VBAC policy. :(

I also wonder how facilities (such as my current employer) that attend births at all can use the justification "No VBACs, because we don't have 24 hour onsite OR, so we aren't equipped for an emergency c-section." Well, if that is a requirement for safety, then you pretty much aren't safe doing any births. I've seen more complications for other things than I have for uterine rupture. That has never made sense to me.

Specializes in L&D.

In my previous life in big city high risk hospitals, we did lots of VBACS. We needed to know the previous incision was a low transverse that healed without infection. We found that about 3/4s of the women who were previously sectioned for CPD or failure to progress were able to VBAC a larger baby than the one they were sectioned for. We cautiously used pit for augmentation as well as induction. We were able to do quick sections when needed. I've seen the baby out within 5 min of mom's helicopter landing on the roof.

Now in a small rural hospital where VBAC is accidental only. We have the 30 min decision to incision rule and can get a baby out in that time period. When there is an emergency, it is terrifying waiting for someone to get there to start. We'll set up the room and be as ready as possible. If anesthesia is there, we may start without the OR crew. I have not been present for one done without anesthesia, but it has happened when the need was too great to wait.

reason for previous section must be other than cephalo-pelvic disproportion

That's interesting considering that true CPD is so rare but the diagnosis is so (over)used. That must rule out a lot of people.

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