VBAC - Safety for the Patient

7/30/2019 VBAC - Safety for the Patient...

1/12

PDFlib PLOP: PDF Linearization, Optimization, Protectio

Page inserted by evaluation versionwww.pdflib.com [email protected]


2/12

January/February 2004 JOGNN 105

CLINICAL ISSUES

VBAC: Safety for the Patient and the NurseJoan Drukker Dauphinee

During the 1970s and 1980s, some women

fought for the opportunity to deliver vaginally after acesarean birth (VBAC). The American College ofObstetricians and Gynecologists initially supportedVBAC for many low-risk women. Inter ventionsincreased and complications of VBAC were reported,however, and recommendations changed. VBACshould be performed in hospitals equipped to care forwomen at high risk. Nurses caring for patients under-going VBAC should be able to recognize and respondto the signs and symptoms of uterine rupture, includ-ing the most common symptom, which is a nonreas-suring fetal monitor tracing. Nurses also should beaware of the necessity for 24-hour blood banking,

electronic fetal monitoring, on-site anesthesia cover-age, and continuous presence of a surgeon. JOGNN,33, 105-115; 2004. DOI: 10.1177/0884217503261160

Keywords: Cesarean birthLiabilitySafetyUterine ruptureVBAC

Accepted: July 2003

When Julius Caesar was allegedly born by cesareandelivery, it changed obstetrics forever! Before thattime, all children were born vaginally, but after thisfirst cesarean delivery, practitioners had an alterna-tive way to deliver babies. With the advent of

abdominal delivery, however, came questions aboutthe safety and cost of a repeat cesarean versus a vagi-nal delivery after having had a previous cesarean. Inthis article, the history of VBAC (vaginal birth aftercesarean) is summarized and nursing considerationsfor patient safety and management of liability duringVBAC are reviewed.

History of Cesarean and VBAC

Cesarean BirthIn Julius Caesars time, cesarean sections were

performed on dead or dying women. Throughoutthe Middle Ages, women had cesarean births only asa last resort, as most women did not survive the pro-cedure. However, some success during the MiddleAges gave hope that the surgery would eventually besuccessful. The first reported case of a woman sur-viving a cesarean section was in 1500 in Switzer-land, where the husband delivered his child when hiswife could not deliver after several days of labor(Sewell, 1993). During the 19th century, saving themothers life became a possibility. It quickly becameclear that cesarean delivery could be helpful whenthere were maternal or fetal complications.

In 1916, Dr. Cragin coined the motto, Once acesarean section, always a cesarean section. He wasconcerned about the rate of primary cesarean deliv-eries and wanted practitioners to avoid the firstcesarean delivery, or the woman would be subjectedto cesarean deliveries with future pregnancies. Atthat time, it was thought to be too dangerous toallow a mother to have a vaginal delivery after acesarean delivery (Flamm, 1997). Even if the motherarrived at the hospital fully dilated, she was takenquickly to the operating room for a cesarean deliv-ery. As a result of this thinking, repeat cesareandeliveries became the standard of care in the UnitedStates by the early 1960s. Anesthesia and surgicaltechniques improved, and the rate of cesarean deliv-ery increased to 5% by 1970 and to 25% by 1988(Carr, Burkhardt, & Avery, 2002). However,


3/12

increased maternal morbidity and mortality and increasedhealth care costs accompanied this growth.

Evolving Standards for VBAC ManagementDuring the 1970s and 1980s, a few women fought for

the opportunity to deliver vaginally after a cesarean. Prac-titioners were concerned about the safety of the mother

and her fetus, but a few allowed their patients to try avaginal delivery after cesarean delivery. Many of thosewere successful. When researchers reported that vaginalbirths after cesarean deliveries (VBACs) could be safe aswell as cost-effective (Gibbs, 1980), practitioners beganallowing more trials of labor after cesareans (TOLACs)and confidence grew as more evidence of good outcomeswas compiled. These triumphs started a national initiativeto decrease the cesarean birth rate, especially repeatcesareans that accounted for one third of all cesareandeliveries (American College of Obstetricians and Gyne-cologists [ACOG], 1999a). Education began for nurses,physicians, and patients to meet this goal.

In 1982, ACOG published its first guidelines for vagi-nal delivery after a previous cesarean birth. These guide-lines indicated that VBACs should occur in hospitalsequipped to care for high-risk mothers, including thepresence of 24-hour blood banking, electronic fetal mon-itoring, on-site anesthesia coverage, and continuous pres-ence of a surgeon.

By 1988, ACOG strongly supported VBAC and hadreduced the specifications for emergency preparedness.Noting that VBAC deliveries had lowered maternal andperinatal mortality rates, eliminated operative and post-operative complications, and shortened the length of hos-pital stay, ACOG suggested that 50% to 80% of selected

women who had low transverse uterine incisions wereable to deliver vaginally. This ACOG committee opinion(1988) sanctioned ambulation in early labor, oxytocinadministration, use of epidural anesthesia, and TOLACfor all women with one or more previous cesarean birthsif there were no contraindications such as previous classi-cal uterine incision. The specific 1982 recommendationsfor emergency preparedness were replaced by a more gen-eral statement that patients should be delivered in hospi-tals with the capacity to handle obstetric emergencies,including having a physician capable of performing acesarean. At such a setting, a cesarean delivery could beperformed in 30 minutes from decision to incision. With

this endorsement from ACOG, VBAC became increasing-ly common.

In its next statement on VBAC in 1994, ACOGaddressed concerns about uterine rupture. The incidenceof uterine rupture with VBAC was reported to be lessthan 1% of all attempted VBACs, and serious conse-quences could be minimized by appropriate intrapartumsurveillance. The most common signs of uterine rupturewere noted to be abrupt changes in fetal heart rate,

including bradycardia or prolonged decelerations. Addi-tional signs of uterine rupture were vaginal bleeding andloss of fetal station, which could occur with or withoutreported pain. ACOG (1994) recommended that plans forrapid diagnosis and intervention be in place before allow-ing women to attempt TOLAC.

ACOG (1994) now recommended that women should

not be coerced into having a VBAC, but that mode ofdelivery should be based on the clinical circumstances andthe patients preference after counseling. Women with oneprevious cesarean should be encouraged to try VBAC,women with more than one previous cesarean should notbe discouraged, but women with prior classical incisionshould be strongly discouraged. The 1994 committeeopinion eliminated the specific recommendation of emer-gency cesarean capability within 30 minutes from deci-sion to incision. It stated that there was no increased riskwith the use of oxytocin and that judicious use ofprostaglandin gel appeared safe, with a caution that norandomized trials had been done. Epidural anesthesia was

still considered safe and thought to be an enticement forwomen who wanted to try VBAC but were afraid thatthey would have another painful labor that would end upin a cesarean delivery. Courses were offered for hospitalsand physicians on how to reduce cesarean delivery ratesand increase TOLACs (Medical Leadership Council,1996).

During this era of change, women were chosen forTOLAC who were likely to have spontaneous vaginaldeliveries. The practitioners hovered near the patient tomake certain all was well. Only women with documentedlow transverse uterine incisions were allowed to attemptVBAC. Women were not chosen for VBAC if they had

had other prior uterine surgery. Most patients were con-tinuously monitored with electronic fetal monitoringaccording to the ACOG guidelines of 1982, 1988, and1994.

Expanding Use of VBAC. With the low incidence ofVBAC complications, practitioners became more confi-dent. Questions arose as to who should be allowed tohave a TOLAC. Could a woman with twins have aTOLAC? Could a woman with a large baby have aTOLAC? Could a woman attempting TOLAC be givenoxytocin? Could a woman attempting a trial of laborhave prostaglandins? Could a woman attempting a trialof labor be given an epidural? The medical communitythought it had answered all of these questions, andwomen were allowed to have prostaglandins, oxytocin,and epidurals. Research indicated that it was safe to allowa woman with a multiple gestation to attempt VBAC(Kobelin, 2001). It was also reported that 70% of womenwere able to deliver infants larger than their previousbabies even after having had a previous cesarean for fail-ure to progress (ACOG, 1988).

106 JOGNN Volume 33, Number 1


4/12

In 1981, the VBAC rate had been only 3%, so theNational Institutes of Health (NIH) and ACOG becameleaders in encouraging a change in practice. Third-partypayers also found VBAC to be financially beneficial, asthe cost of a vaginal delivery was much less than a cesare-an delivery, and so they also encouraged VBAC and oftenrequired TOLAC (ACOG, 1999a; Medical Leadership

Council, 1996). Consequently, physicians at times feltpressured to attempt TOLAC in clinically unsuitablepatients and patients who did not want the procedure.

Emerging Complications ofVBAC in High-Risk Women

With the great increase in VBAC rates and inclusion ofwomen previously thought to have contraindications toTOLAC, some hospitals were not equipped to handle theemergencies that occurred. These hospitals lacked thenecessary provisions for the physician to be availablewithin the obstetric unit or for operating room personnel

and anesthesia to be available within the hospital duringthese TOLACs. When a uterine rupture occurred, it tooktoo long to deliver the baby by cesarean, which resultedin fetal or neonatal demise or long-term sequelae. Leung,Leung, and Paul (1993) found that in women with anunknown uterine scar, neonatal morbidity was significantwhen greater than 18 minutes elapsed between the onsetof prolonged decelerations and delivery. Many hospitalscould not meet the 30-minute decision-to-incision param-eter and therefore could not deliver a patient in less than18 minutes if a uterine rupture occurred.

Other maternal and fetal complications also occurred.Hysterectomy sometimes was needed. Some women

encountered long and difficult labors in their attempt atVBAC. Some of these women had gynecologic problemslater in life that included urinary and fecal incontinence,pelvic pain, sexual dysfunction, and pelvic prolapse(Devine, Ostergard, & Noblett, 1999; Forsnes, Browning,& Gherman, 2000; Kattan, 1997; Webb, Gilson, & Gor-don, 2000). Perinatal morbidity attributed to TOLACincluded cerebral palsy and fetal or neonatal death. Theseadverse events led to malpractice suits that promptedACOG to reevaluate its recommendations for cesarean(ACOG, 1999a).

ACOG published additional bulletins on vaginal birthafter previous cesarean delivery (1999a), and on induc-

tion and misoprostol (1999b, 1999c, 2000). External ver-sion was added to the list of procedures deemed safe forwomen after previous cesarean. It was also concludedthat women were more likely to try VBAC if epiduralanesthesia was offered and that it did not mask the painof uterine rupture. However, some cautions were intro-duced. Misoprostol was not recommended for TOLAC orfor women with previous uterine surgery. It was notedthat reduction of hospital costs was no longer a simple

rationale for VBAC, as costs of maternal and neonatalcomplications, as well as malpractice costs, should betaken into consideration. Clark et al. (2000) likewise con-cluded that when neonatal care and malpractice costswere included, it was unlikely that VBAC offered signifi-cant cost savings over a repeat cesarean section.

Selection criteria for candidates for VBAC and con-

traindications were listed. Concern was expressed aboutcontinued expansion of those eligible for VBAC toinclude women with multiple previous cesarean deliveries,unknown uterine scars, breech presentations, twin gesta-tions, postterm pregnancies, and suspected macrosomia.Continued analysis was called for before these womencould be routinely offered TOLAC. Oxytocin usage wascondoned, but with the caution that higher doses mightincrease the risk of uterine rupture. There had been occa-

sional reports of uterine rupture with prostaglandinpreparations. ACOG also recommended that after a uter-

ine rupture, the next delivery should be by cesarean, assoon as the baby was mature.

There has been some concern that the type of uterineclosure during cesarean repair could increase the rate ofuterine rupture, but Flamm (2001) stated that single-layerclosure of the uterus was not associated with an increasein uterine rupture in his facility. The amount of timebetween the previous delivery by cesarean and theTOLAC had also been thought to contribute to the uter-ine rupture. Esposito, Menihan, and Malee (2000) foundthat when the interpregnancy interval was less than 6months, it significantly increased the uterine scar failure,and the longer the interpregnancy interval, the lower the

likelihood of uterine scar failure during subsequent labor.ACOGs (1999a) recommendations included continu-

ous fetal monitoring and the presence of personnel whowere familiar with VBAC complications, including nonre-assuring fetal monitoring tracings and signs of inadequatelabor progress. TOLAC was specifically contraindicatedin situations in which there was an inability to performemergency cesarean because of unavailable surgeon, anes-thesia, sufficient staff, or facility. In a later statewide


The risk of uterine rupture was approximately5.2 per 1,000 in women attempting a trial

of labor after cesarean whose labors

were not induced. The risk increased

with induced labor.


5/12

study in Ohio (Lavin, DiPasquale, Crane, & Stewart,2002), it was found that many Level I and II hospitalsprovided less than optimal staffing for women undergo-ing TOLAC.

Concern About Oxytocin Induction in TOLACLeung, Farmer, Leung, Medearis, and Paul (1993) had

found years earlier that high doses of oxytocin in TOLACwere associated with uterine rupture. Lydon-Rochelle,Holt, Easterling, and Martin (2001) reported that therisk of uterine rupture was approximately 5.2 per 1,000TOLACs in women who were not induced, but the riskincreased to 7.7 per 1,000 when women were inducedwith oxytocin, and to 24.5 per 1,000 when women alsowere given prostaglandins, particularly misoprostol. TheInternational Childbirth Education Association (ICEA),as early as 1997, discouraged the use of oxytocin inTOLAC and subsequently criticized ACOG for notexpressing greater caution about using oxytocin after theLydon-Rochelle report. Lieberman (2001) likewise indi-

cated that there should be some concern about using oxy-tocin for a TOLAC. Blanchette, Blanchette, McCabe, andVincent (2001) found that 11 of the 12 uterine rupturesthat they reviewed had occurred during induction withoxytocin, and Sims, Newman, and Hulsey (2001) foundthat induction significantly reduced the rate of successfulvaginal delivery and increased the risk of serious maternalmorbidity.

Not all reports were negative. Kobelin (2001) reportedthat it was safe to give oxytocin to TOLAC patients,although high doses of oxytocin could increase the risk ofuterine rupture. Flamm (2001) reviewed the literature andfound that oxytocin was safe to use for TOLAC, but cau-

tioned that because uterine rupture was associated withoxytocin without a uterine scar that it would be wise toexercise caution when administering oxytocin with ascarred uterus. Hamilton, Bujold, McNamara, Gauthier,and Platt (2001), reviewing cases of symptomatic uterinerupture, suggested that it was not induction itself but con-tinued use of oxytocin with unidentified dystocia that wasassociated with uterine rupture. They concluded that incases in which cervical dilation was arrested for 2 hoursor more, cesarean delivery would have prevented 42.1%of uterine ruptures.

In 2002, ACOG published another committee opinionthat discouraged the use of prostaglandins for cervical

ripening or induction of labor. This opinion reiteratedthat misoprostol should not be used in VBAC patients butnoted that VBACs could continue under proper circum-stances and with appropriate safeguards, as described inthe 1999a practice bulletin. ACOG continues to supportthe use of oxytocin for TOLACs.

Knowing the Signs of Uterine RuptureGiven the potential lethal complications of uterine rup-

ture that include maternal morbidity such as hysterecto-my and neurological impairment in infants or even peri-natal death, obstetric staff must have appropriateequipment and personnel, including a surgeon, anesthe-sia, and surgery personnel immediately available to deal

with emergencies. Some authors have defined immediate-ly available as remaining in the hospital during a TOLAC(Blanchette et al., 2001).

Obstetric nurses and physicians must also understandthe signs and symptoms of uterine rupture. These symp-toms may include abdominal, shoulder, or back pain. Thepain is usually not masked by an epidural; patients havereported pain even with an epidural that had previouslybeen giving them pain relief. Vaginal bleeding may also bea symptom of uterine rupture, although it does not seemto be common. Occult bleeding may cause hypovolemiaand be manifested by abnormal vital signs.

Signs of uterine rupture exhibited by the fetus include

the movement of the fetal presenting part to a higher sta-tion. This occurs when the fetus moves up into theabdomen from the uterus after uterine rupture. At times,uterine activity on the fetal monitor demonstratestachysystole. There could be cessation of uterine activity,but this may be a later sign. The cessation of uterine activ-ity may come after the tachysystole or may occur inde-pendently. However, many authors have stated that usu-ally there is no disruption of the uterine activity(Blanchette et al., 2001; Flamm, 1992; Menihan, 1998;Ramsey, Johnston, Welter, & Ogburn, 2000).

The most significant sign of uterine rupture describedin the literature is a change in the fetal heart rate tracing(Blanchette et al., 2001; Cowan, Kinch, Ellis, & Ander-son, 1994; Kieser, 2002; Leung, Farmer, et al., 1993;Menihan, 1998), which was described as early as 1992 byFlamm. Several authors have indicated that when uterine

rupture occurs, variable decelerations are frequently seen,or they have reported cases of variable decelerations fol-lowed by bradycardia (Ramsey et al., 2000; Webb et al.,2000). However, others have indicated that bradycardiacan occur without preceding decelerations (Bennett,1997; Flamm, 2001; Menihan, 1999). Others have indi-cated that late decelerations and/or variable decelerations


The most significant sign of uterine rupture ischange in the fetal heart rate tracing.


6/12

precede bradycardia (Leung, Farmer, et al., 1993; Meni-han, 1998).

Flamm (2001) remarked that variable decelerations areseen frequently in the second stage of labor, but when

they are consistent and severe and do not respond to nurs-ing intervention or are severe enough that amnioinfusionis considered, it would be more prudent to considercesarean section instead. Flamm also cautioned that a


Case

1 2 3 4 5 6 7 8

Prostaglandins Misoprostol Prostaglandin Cervidil None None None None Misoprostol

50 mcg 2 gel 50 mcg 1

Pitocin No Yes Yes No Yes Yes Yes Yes

Epidural Yes Yes Yes Yes Yes No Yes Yes

N&V None No None Yes No No Yes Yes

Maternal Stable Stable Blood pressure Blood pressure Stable Not Pulse Pulsevital signs decreased decreased assessed increased increased

Pulse increased Pulse increased

Vaginal bleeding None None None Bloody No No No Noamniotic fluid

Unusual pain No Shoulder pain Yes No Pelvic pain No Yes Pain 1-2,epiduralincreased

EFM US/Toco FSE/Toco US/Toco FSE/Toco FSE/Toco FSE/Toco US/Toco US/IUPC

Decelerations Variable Variable, late, Variable Variable Variable Variablea Variable Lateb

prolonged

Terminal Yes Yes Yes Yes Yes Yesd Yes NoBradycardia

Contractions Hyper- Hyper- Slowed, then Ceasedc Toco Ceased Continued Continuedstimulation, stimulation, hyper- discontinuedthen ceased then mild stimulation

contractions,then ceased

Minutes of 58 69 90 72 129 55 23 140nonreassuringtracing

Minutes of 49 15 13 21 15 34 31 0bradycardia

Second-stage No Yes Yes Yes Yes Yes Yes Norupture

MD in hospital No Yes No Yes No No No Yes

Apgars 12 1-1 1-1 1-1 1-1 1-0 1-0 1-053 5-2 5-4 5-2 5-1 5-0 5-4 5-010-5 10-4 10-5 102 105 100 10-4

Outcome Cerebral Cerebral Cerebral Death in Cerebral Stillborn Cerebral Death inpalsy palsy palsy NICU palsy palsy NICU

aSee Figure 1a.

bSee Figures 2a and 2b.

cSee Figure 3b.

d

See Figure 1b.

TABLE 1

Clinical Presentations of Eight Cases of Ruptured Uterus


7/12

deceleration of the fetal heart rate to 60-70 beats perminute or less for more than a few minutes that does notreturn to baseline requires rapid intervention.

Fetal Heart Rate Tracings During

Uterine Rupture: Case ReviewsTo promote safety for patients and in nursing practice,

nurses can learn from review of fetal heart rate patternsduring uterine rupture. Eight cases of uterine rupturewere reviewed to identify the symptoms of uterine rup-ture. Seven were TOLACs and one occurred in a multi-gravida during labor without a previous cesarean section.

Three of the babies died: one was stillborn and two diedin the neonatal intensive-care unit (NICU). The other fivebabies had neurological sequelae, including cerebral palsy(see Table 1).

EFM PatternsThe fetal monitoring tracings from these eight casessupported the evidence cited above that a nonreassuringfetal monitoring tracing is the first sign of uterine rupture.All were nonreassuring. There were variable, late, andbradycardic patterns, and the most frequent pattern wasthat of variable decelerations (see Figure 1a) progressingto bradycardia (see Figure 1b). It is thought that the


FIGURES 1A AND 1B

Two segments of fetal monitor tracings from case 6, showing variable decelerations at 1900 (a) progressing to bradycardia at 1950(b).

FIGURES 2A AND 2BTwo segments of fetal monitor tracings from case 8, showing late decelerations at two time points in over 2 hours of oxtytocininduction, with declining heart rate variability (b).


8/12

umbilical cord extrudes through the rupture and causescord compression, producing variable decelerations. Onetracing had variable, late, and prolonged decelerationsbefore bradycardia. Six of the eight ruptures occurred inthe second stage of labor. Many of the practitionersthought that since variable decelerations were common inthe second stage of labor, they were not a symptom ofuterine rupture. This delayed the recognition of uterinerupture in most of the cases.

The tracing from the multigravida without previouscesarean showed late decelerations (see Figure 2a and 2b)and was the only one that did not demonstrate bradycar-

dia, although variability was absent by the end of thelabor. Late decelerations reflect uteroplacental insufficien-cy that is thought to be caused by placental interference atthe rupture site. In this case, the placenta delivered withthe infant.

In four cases, a fetal scalp electrode was not applied, sothe variability could not be completely assessed. Althoughtime of onset was unknown, seven of the tracings demon-strated minimal to absent variability along with decelera-tions. The eighth tracing had average variability with sec-tions of saltatory baseline.

The uterine activity was not consistent. Normal uterineactivity continued in two of the cases. In two of the cases,

uterine hyperstimulation was seen, and then contractionsstopped. In two other cases, the uterine activity simplyceased (see Figure 3a and 3b). In a fifth, the uterine activ-ity slowed down, followed by hyperstimulation. In onecase, the tocotransducer was removed, so uterine activityis unknown. In hindsight, because six of these eightpatients were receiving oxytocin, practitioners should

have been especially watchful for dystocia (Hamil-ton et al., 2001).

Maternal Symptoms and Obstetric InterventionsSix of the eight patients received oxytocin, and four

received prostaglandins; two of these received 50 mcgmisoprostol. Three of the four patients who receivedprostaglandins also received oxytocin. It is of interest thatsix of the eight uterine ruptures in this series occurred inthe second stage of labor, and of those, two had vacuumattempts and one had a forceps attempt.

All but one of the patients had epidurals. The patient

without an epidural did not experience increased pain,and two of the patients with epidurals did not haveincreased pain. It was documented that one of the patients(case 8) had a pain level of 1-2; however, at that time herepidural medication dose was increased. The otherpatients had pain in different places: One had shoulderpain, two had increased uterine pain, and one had pelvicpain. It is interesting that the patient without an epiduraldid not complain of increased pain, yet some of thepatients with epidurals were still able to feel pain.Although TOLAC patients were not given epidurals inearly years because it was thought the epidurals wouldmask the pain of uterine rupture, these cases reflect that

epidurals are now freely administered.Other commonly anticipated symptoms of uterine rup-

ture were seen only inconsistently in these cases. Only twopatients complained of nausea and vomiting. Only onehad bleeding, in the form of bloody amniotic fluid. Twopatients had the expected decrease in blood pressure andincrease in pulse, and two had only an increased pulse.


FIGURES 3A AND 3BTwo segments of fetal monitor tracings from case 4, showing regular uterine contractions at 4:20 (a) progressing to cessation ofuterine contractions by 5:09 (b).


9/12

Three women had no change in vital signs. There was novital sign assessment for one of the patients.

Seven of the eight cases occurred in community hospi-tals that were unable to provide anesthesia, sufficientstaff, or a surgeon capable of performing an immediatecesarean. None of them met the 30-minute decision-to-incision criterion, let alone the 18-minute time limit sug-gested by Leung, Leung, et al. (1993). Table 1 outlines thelength of time that elapsed from the onset of an ominoustracing until delivery. However, in all the cases, a nonre-assuring tracing preceded the ominous tracing. In all butone of the cases, the surgeon was not in the hospital,which prolonged the time to surgical delivery. These casesdemonstrate the importance of vigilant assessment fornonreassuring fetal monitor tracings, the most consistentand significant symptom of uterine rupture.

Nursing Implications

These case studies emphasize the importance of therecommendations made by ACOG and others to keep thepatient, the nurse, and the physician safe. These recom-mendations are listed in Table 2. When these recommen-dations can be met, TOLAC can be performed in an envi-ronment that will be able to handle the acute emergencyof uterine rupture.

DocumentationRecord-keeping is an important component of safe

patient care. When an emergency occurs, it is imperativeto take care of the patient, but also to keep track of theplan of care, interventions, their timing, and the patients

response. The nurse or physician may only have a few sec-onds to jot down information. The fetal monitoring trac-ing is a good place to do this, as it automatically keepstrack of the time that events occurred. In most of thecharts and tracings reviewed from these cases, there wasvery little information about what was happening with

the patient. In case 3, the physician noted the indicationfor the cesarean delivery as failed forceps delivery, andthere was no indication that the patient was being treatedfor an emergency. Documentation assists with communi-cation and maintains a record of emergency situations.This is important for dissemination of accurate informa-tion to other care providers such as the intensive-care unit(ICU) or the NICU.

ConsentFully informed consent also is essential for the woman

who wants to have a trial of labor after a cesarean sec-tion. The patient must be advised regarding the risks aswell as the benefits of TOLAC. She must understand theramifications of uterine rupture, even though the risk issmall. She should also be informed that there is a higherrisk of uterine rupture with an induction than with spon-taneous labor.

This consent should be in writing and should be signedin the physicians office before admission for the actualdelivery. The benefits and risks should be clearly delineat-ed on the consent form. A copy should be sent with thewomans prenatal records to the hospital. When thepatient is admitted to the hospital, the nurse must ensure

that informed consent has been provided, by asking thepatient if she understands the procedure and the benefitsand risks of the TOLAC, including the risk of uterine rup-ture. If she has not been given this information or doesnot understand, the procedure with its risks and benefitsshould be explained to the patient. If the patient still hasquestions, the physician should be contacted to discussthese issues with the patient. To optimize patients under-


TABLE 2

ACOG 2002 Recommendations for Safe VBAC

Signed informed consent with benefits and risks listed

Appropriate patients chosen by medical personnel for VBAC

Appropriate method of initiation of labor, that is, sponta-

neous or oxytocin inductionSurgeon in the hospital

Anesthesia provider in the hospital

Operating room personnel in the hospital

Sufficient blood available in the hospital

Ability to perform cesarean delivery in < 18 minutes

Practitioner at bedside who can interpret nonreassuring fetalmonitoring tracings

Practitioner at bedside who can recognize signs and symp-toms of uterine rupture

Source: ACOG (2002).

The woman considering induction of laborafter previous cesarean birth should be

informed that there is a higher risk of uterine

rupture with an induction than

with spontaneous labor.


10/12

standing of the procedures and risks, a pamphlet may bewritten by the nursing and medical staff and given to thepatient in the office by the physician when he or sheexplains the procedure and the consent is signed. Thispreapproved pamphlet could also be given to hospitalizedpatients who have not received the full explanation of theprocedure and its risks.

Even when the patient is in labor, she may change hermind and decide to have a cesarean birth. If the patientreports that she now wants a cesarean birth, the physicianand hospital no longer have consent for a VBAC, and theTOLAC should not be continued. Continuing theTOLAC after the patient has withdrawn her consent putsthe nurses, physicians, and hospital at risk for a lawsuit,even if no harm to the fetus or infant occurs.

SurveillanceA nonreassuring fetal monitor tracing in a TOLAC

patient should alert the caregivers to the possibility ofuterine rupture. Based on these cases and the literature

cited above, any nonreassuring fetal monitor tracingshould be suspect. Therefore, an expert in reading fetalmonitor tracings must be constantly available to evaluatethe tracings. If there is any question at all of a nonreas-suring tracing, the nurse should apply a fetal scalp elec-trode or have one applied. The fetal scalp electrode willinitiate a clearer, more accurate tracing for ongoing andlater evaluation.

All of the tracings in the cases reviewed had late, vari-able, and/or prolonged decelerations with minimal toabsent variability before the terminal bradycardia. Themost common pattern before the terminal bradycardiawas variable decelerations. Many of the cesarean deliver-

ies were delayed because the nurses and/or the physiciansthought that the variable decelerations reflected thosecommonly occurring in the second stage of labor.

In all of the tracings, loss of variability along with thesedecelerations reflected an ominous fetal heart rate tracingbefore the terminal bradycardia. Even in a low-risk labor,the combination of decelerations and minimal to absentvariability is ominous, and the fetus should be delivered.Terminal bradycardia should be considered an emergencyin patients who are undergoing a TOLAC, and the nurseshould assemble the team for an emergency delivery.However, in all of the tracings, the terminal bradycardiawas preceded by decelerations and minimal to absent

variability in those cases where it could be assessed. Vari-ability may have been absent in all of the tracings, but afetal scalp electrode was not utilized in all of the tracingsto assess the exact absence of variability. Any delay by thenurse in the process of identifying the nonreassuring trac-ing or assembling the team could mean damage for themother and/or the fetus and a lawsuit for the hospital. In

these cases, assembling the team when the ominous decel-erations occurred before the terminal bradycardia wouldhave saved valuable time in getting the baby delivered. Inmost cases, the fetus would have been delivered before theterminal bradycardia.

Readiness for Emergency

According to ACOG criteria for safe TOLAC, thephysician, anesthesia provider, and operating room teammust be immediately available, but ACOG has notdefined immediately available. If we define immediatelyavailable based on the study by Leung, Leung, et al.(1993), the fetus should be able to be removed from theruptured uterus in less than 18 minutes to avoid braindamage. Hospitals should develop policies to identifywhat immediately available means in their settings.

In many hospitals today, the decision has been madethat the physician, anesthesia provider, and operatingroom team need to be in the hospital at all times during aTOLAC. Some hospitals have decided not to allow

TOLACs because they cannot meet these criteria. In somecases, physicians will not stay at the hospital, and thehospital does not have residents available to initiate thesurgery. Some hospitals do not have 24-hour in-hospi-tal anesthesia coverage or nurses available at all times toscrub and circulate. Allowing TOLACs when these serv-ices are not available places the mother, fetus, and hospi-tal at risk.

Personnel who are experts at reading fetal monitoringtracings and can quickly assemble the operative team arethe key to swift deliveries when emergencies occur.Appropriate selection of patients who can labor in a set-ting where the surgeon and anesthesia and operating

room personnel are present can make the experience ofvaginal birth after cesarean safer for all involved.

REFERENCES

American College of Obstetricians and Gynecologists. (1982).Guidelines for vaginal delivery after a previous cesareanbirth (Committee on Obstetrics: Maternal and Fetal Med-icine). Washington, DC: Author.

American College of Obstetricians and Gynecologists. (1988).Guidelines for vaginal delivery after a previous cesareanbirth (Committee opinion 64). Washington, DC: Author.

American College of Obstetricians and Gynecologists. (1994).Guidelines for vaginal delivery after a previous cesarean

birth (Committee opinion 143, replaces #64 October1988). Washington, DC: Author.

American College of Obstetricians and Gynecologists. (1999a).Vaginal birth after previous cesarean delivery (ACOGpractice bulletin 5). Washington, DC: Author.

American College of Obstetricians and Gynecologists. (1999b).Induction of labor (ACOG practice bulletin 10). Wash-ington, DC: Author.



11/12

American College of Obstetricians and Gynecologists. (1999c).Induction of labor with misoprostol(Committee opinion228). Washington, DC: Author.

American College of Obstetricians and Gynecologists. (2000).Response to Searles drug warning on misoprostol(Com-mittee opinion 248). Washington, DC: Author.

American College of Obstetricians and Gynecologists. (2002).Induction of labor for vaginal birth after cesarean delivery

(Committee opinion 271). Washington, DC: Author.Bennett, B. B. (1997). Uterine rupture during induction at term

with intravaginal misoprostol. Obstetrics and Gynecolo-gy, 89, 832-833.

Blanchette, H., Blanchette, M., McCabe, J., & Vincent, S.(2001). Is vaginal birth after cesarean safe? Experience ata community hospital. American Journal of Obstetricsand Gynecology, 184, 1478-1487.

Carr, C. A., Burkhardt, P., & Avery, M. (2002). Vaginal birthafter cesarean birth: A national survey of US midwiferypractice. Journal of Midwifery and Womens Health, 47,347-352.

Clark, S. L., Scott, J. R., Porter, T. F., Schlappy, D. A., McClel-lan, F., & Burton, D. A. (2000). Is vaginal birth after

cesarean less expensive than repeat cesarean section?American Journal of Obstetrics and Gynecology, 182,599-602.

Cowan, R. K., Kinch, R. A. H., Ellis, B., & Anderson, R. (1994).Trial of labor following cesarean delivery. Obstetrics andGynecology, 83, 933-936.

Cragin, E. B. (1916). Conservatism in obstetrics. New YorkMedical Journal, 104, 1-3.

Devine, J. B., Ostergard, D., & Noblett, K. (1999). Long-termcomplications of the second stage of labor. ContemporaryOB/GYN, 44(6), 846-848.

Esposito, M. A., Menihan, C. A., & Malee, M. P. (2000). Asso-ciation of interpregnancy interval with uterine scar failurein labor: A case-control study. American Journal of

Obstetrics and Gynecology, 183, 1180-1183.Flamm, B. L. (1992). Roundtable discussion: Should the elec-

tronic fetal monitor always be used for women in laborwho are having a vaginal birth after a previous cesareansection? Birth, 19, 31-34.

Flamm, B. L. (1997). Once a cesarean, always a controversy.Obstetrics and Gynecology, 90, 312-315.

Flamm, B. L. (2001). Vaginal birth after cesarean: Reducingmedical and legal risks. Clinical Obstetrics and Gynecol-ogy, 44, 622-629.

Forsnes, E. V., Browning, J. E., & Gherman, R. B. (2000). Blad-der rupture associated with uterine rupture. Journal ofReproductive Medicine, 345, 240-242.

Gibbs, C. E. (1980). Planned vaginal delivery following cesare-

an section. Clinical Obstetrics and Gynecology, 23, 507-515.

Hamilton, E. F., Bujold, E., McNamara, H., Gauthier, R., &Platt, R. W. (2001). Dystocia among women with symp-tomatic uterine rupture. American Journal of Obstetricsand Gynecology, 184, 620-624.

International Childbirth Education Association. (1997). Posi-tion statement: Cesarean birth and VBAC. InternationalJournal of Childbirth Education, 12(4), 38-41.

Kattan, S. A. (1997). Maternal urological injuries associatedwith vaginal deliveries: Change of pattern. InternationalUrology and Nephrology, 29, 155-161.

Kieser, K. E. (2002). A 10 year population-based study of uter-ine rupture. Obstetrics and Gynecology, 100, 749-753.

Kobelin, C. G. (2001). Intrapartum management of vaginalbirth after cesarean section. Clinical Obstetrics and Gyne-cology, 44, 588-593.

Lavin, J. P. Jr., DiPasquale, L., Crane, S., & Stewart, J. Jr.(2002). A state-wide assessment of the obstetric, anesthe-sia, and operative team personnel who are available tomanage the labors and deliveries and to treat the compli-cations of women who attempt vaginal birth after cesare-an delivery. American Journal of Obstetrics and Gynecol-ogy, 187, 611-614.

Leung, A. S., Farmer, R. M., Leung, E. K., Medearis, A. L., &Paul, R. H. (1993). Risk factors associated with uterinerupture during trial of labor after cesarean delivery: Acase-control study. American Journal of Obstetrics andGynecology, 168, 1358-1363.

Leung, A., Leung, E., & Paul, R. (1993). Uterine rupture afterprevious cesarean delivery: Maternal and fetal conse-

quences. American Journal of Obstetrics and Gynecology,169, 945-950.

Lieberman, E. (2001). Risk factors for uterine rupture during atrial of labor after cesarean. Clinical Obstetrics and Gyne-cology, 44, 609-621.

Lydon-Rochelle, M., Holt, V. L., Easterling, T. R., & Martin, D. P.(2001). Risk of uterine rupture during labor amongwomen with prior cesarean delivery. New England Jour-nal of Medicine, 345, 3-8.

Medical Leadership Council. (1996). Coming to term: Innova-tions in safely reducing cesarean rates. Washington, DC:The Advisory Board Co.

Menihan, C. A. (1998). Uterine rupture in women attempting avaginal birth following prior cesarean birth. Journal of

Perinatology, 18(6), 440-443.Menihan, C. A. (1999). The effects of uterine rupture on fetal

heart rate patterns. Journal of Nurse-Midwifery, 44(1),40-46.

Ramsey, P. S., Johnston, B. W., Welter, V. E., & Ogburn, P. L. Jr.(2000). Artifactual fetal electrocardiographic detectionusing internal monitoring following intrapartum fetaldemise during VBAC trial. Journal of Maternal-FetalMedicine, 9, 360-361.

Sewell, J. (1993). Cesarean section: A brief history. Washington,DC: The American College of Obstetricians and Gynecol-ogists in cooperation with the National Library of Medi-cine. Retrieved Sept. 16, 2003, from http://www.nlm.nih.gov/exhibition/cesarean/cesarean_1.html

Sims, E. J., Newman, R. B., & Hulsey, T. C. (2001). Vaginalbirth after cesarean: To induce or not to induce. AmericanJournal of Obstetrics and Gynecology, 184, 1122-1124.

Webb, J. C., Gilson, G., & Gordon, L. (2000). Late second stagerupture of the uterus and bladder with vaginal birth aftercesarean section: A case report and review of the litera-ture.Journal of Maternal-Fetal Medicine, 9, 362-365.



12/12

Joan Drukker Dauphinee, RNC, MS, is a unit-based educatorfor Womens and Surgical Services, Orlando Regional SouthSeminole Hospital, Longwood, FL.

Address for correspondence: Joan Drukker Dauphinee, RNC,MS, Womens and Surgical Services, Orlando Regional SouthSeminole Hospital, 55 West State Road 434, Longwood, FL32750. E-mail: [email protected].


Documents

VBAC - Safety for the Patient