Counseling patients about vaginal birth after cesarean

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When I first became a labor and delivery nurse, we often heard the phrase, “Once a cesarean-section, always a cesarean-section.” Very few women were given the option to attempt a vaginal birth after cesarean (VBAC) because of the fear of uterine rupture at the site of the cesarean scar. 

Now, I consider myself lucky to work in a progressive practice that allows and encourage VBAC for all appropriate candidates, but there are still many practices that do not allow their patients the option of attempting a trial of labor after cesarean (TOLAC).  

In an attempt to decrease rising U.S. cesarean-section (c-section) rates, the newest American College of Obstetricians and Gynecologists (ACOG) guidelines give health care providers more leeway to consider individual patients for TOLAC, rather than placing hard and fast restrictions on management decisions.

One of the biggest guideline changes is the recommendation that clinicians should extend the option of TOLAC to women with two prior cesareans after discussing the risks and benefits at length. Although I agree with these recommendations it's often challenging to help patients that desire TOLAC maintain realistic expectations.

Each women's obstetric and delivery history, as well as the course of the current pregnancy, must be discussed on a case-by-case basis. Let us consider the following two patients:

The first patient, O.B., is a 28-year-old gravida two para one, who had a failed labor induction at 40 weeks during her first pregnancy four years prior. She had never been in active labor, but after a day of pitocin administration, her health care provider decided to proceed to a c-section delivery due to lack of cervical change. The patient was unhappy with this outcome and was very motivated to have a VBAC in the future. 

During the patient's second pregnancy, her cervix remained unfavorable at 40 weeks. I reminded her that she needed to go into labor on her own for TOLAC, as our practice does not induce labor after a previous c-section. We discussed the growing possibility of a repeat cesarean, but she insisted that we wait until the last possible time — 41 weeks and six days gestation — to schedule her procedure. 

At 41 weeks, the patient presented to the hospital 9-cm dilated in active labor.  She gave birth to an 8-lb viable male after a three-hour labor and had a successful, unmedicated VBAC. The patient was very happy with this outcome!

The second patient, C.L., is a 26-year-old gravida three para two that had a cesarean birth four years prior for breech presentation, then a repeat c-section two years ago after a failed TOLAC at 38-weeks gestation. She had progressed to complete cervical dilation and pushed for two hours before undergoing c-section for arrest of descent.

After reading the most recent ACOG guidelines, C.L. requested another TOLAC for her third pregnancy. I had to tell her that she was not the best candidate, given her delivery history.

But after consulting with my backup physicians, I told the patient that she could attempt a TOLAC if she went into spontaneous labor. However, I warned her that we would have a low threshold for cesarean should labor or descent stall. The patient was agreeable to this plan, however when she did not go into spontaneous labor by 40 weeks, she elected to have a repeat c-section.

Though both patients desired VBACs, their obstetric histories were vastly different and each required very specific counseling regarding risks, benefits and realistic management options for birth.

I believe the flexibility of the ACOG's new guidelines is just one step towards placing clinical decision back into the realm of those best suited to make them and is effective in decreasing health-care providers' fear of litigation during everyday practice.

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