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VBAC Presentation Mitchell

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Lori Ryba

on 10 June 2013

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Transcript of VBAC Presentation Mitchell

History of the VBAC Dr. Edwin Cragin coined the phrase "once a Cesarean, always a Cesarean" in an attempt to dissuade physicians from performing an initial C-section.
The feminist movement of the 1970's and 1980's gave way to many women who wished to change this view
Physicians began strictly using transverse incision instead of the vertical incision for the c-section. What is a VBAC A VBAC is a vaginal birth after Cesarean section
TOLAC is a trial of labor after Cesarean section with an attempt to experience a vaginal delivery
ERCD is an elective repeat Cesarean delivery VBAC
(Vaginal Birth After Cesarean) The Risks and Benefits Statistics
1970 to 2007 Cesarean delivery went from 5% to more than 31%
VBACs began to rise 5% in 1985 to 28.3% in 1996 and Cesarean decreased to 20%
With this increase, uterine rupture increased
VBAC rate decreased to 8.5% by 2006 and the total Cesarean delivery rate increased to 31.1%
Today some doctors and hospitals will refuse a VBAC Benefits of a VBAC Provides the vaginal birth experience
Avoiding a major abdominal surgery
Lower rates of hemorrhage and infection
Shorter recovery period
Shorter hospital stay Necessary Criteria According to the ACOG guidelines published in 2004 the following criteria must be met in order to receive a VBAC:
A previous caesarian with a low transverse incision
An adequate pelvis
An absence of uterine scarring other than the previous CD
A physician must be on standby during active labor in the even an emergency CD is needed Megan Biglin
Megan Gainforth
Lori Ryba
Simcha Tova Schreiber Risks to Mother
(ERCD and TOLAC) Hemorrhage
Infection, leading to sepsis
Operative injury
Thromboembolism
Hysterectomy
Death Risks to the Baby Uterine Rupture Uterine rupture is often associated as the main risk of TOLAC
Women with a low transverse uterine incision had a uterine rupture rate of 0.5-0.9% with a VBAC
The mother may need a hysterectomy, blood transfusion, develop hypovolemia, shock, or placental abruption Legal Implications Nursing Implications References Maternal Risks Endometritis
Operative injury
Blood transfusion
Hysterectomy
Uterine rupture
Maternal death Risks TOLAC(%) ERCD (%) 1.5-2.1
0.42-0.6
1-1.4
0-0.4
0.4-0.5
0.02-0.04 2.9
0.4
0.7-1.7
0.2-0.5
0.7-0.9
0.02 (Ecker & Grobman, 2010) (Dickerson, 2010) (ACOG, 2010) ERCD Iatrogenic prematurity
Impaired adaptation to extrauterine life
Risk of respiratory issues at birth
Risk of lifetime respiratory issues
Delayed/impaired breasfeeding and bonding (Dickerson, 2010) Effective screening involves a thorough education on the risks of VBAC, making sure all the criteria are met, and consent forms are signed (Andrews & Humphries, 2010).
An understanding of medication safety in VBAC patients. The use of prostoglandins like misoprostol for cervical ripening is not advised due to an increase of uterine rupture in VBAC patients (Macones, 2010). Actually A Risk? (Lowdermilk & Perry, 2007) (Baxter & Davies, 2010) Common Allegations referenced in VBAC lawsuits
Failure to give a full informed consent including risks and benefits
Use of prostoglandins in women with previous uterine scarring
Excessive pitocin usage to induce labor
Failure to recognize signs of uterine rupture
Failure to treat uterine rupture immediately, failure to monitor FHT
Failure to be equipped with appropriate personnel and supplies
Failure to document the progression of labor
Andrews, D., & Humphries, G. (2010). After a cesarean...what's a birth professional to do?. Journal Of Perinatal Education, 19(2), 11-15. doi:10.1624/105812410X495505

Baxter, L., & Davies, S. (2010). Balancing risk and choice in childbirth after caesarean section. British Journal Of Midwifery, 18(10), 638-643.

Cohain, J. (2006). Vaginal birth after caesarean section: seeing the bigger picture. British Journal Of Midwifery, 14(7), 424-426.

Dickerson, T. (2010). The rise and fall of VBAC in the United States.Journal Of Legal Nurse Consulting, 21(1), 3-8. Risks to the Baby VBAC Retrieved from: (Lowdermilk & Perry, 2007) (Scott, 2011) References Korst, L., Gregory, K., Fridman, M., & Phelan, J. (2011). Nonclinical factors affecting women's access to trial of labor after cesarean delivery. Clinics In Perinatology, 38(2), 193-216. doi:10.1016/j.clp.2011.03.004

Lowdermilk, D. L., & Perry, S. E. (2007). Maternity and women's health care. Mosby Inc.

McGrath, P., Phillips, E., & Vaughan, G. (2010). Vaginal birth after Caesarean risk decision- making: Australian findings on the mothers' perspective. International Journal Of Nursing Practice, 16(3), 274-281. doi:10.1111/j.1440-172X.2010.01841.x

Menacker, F., MacDorman, M., & Declercq, E. (2010). Neonatal mortality risk for repeat cesarean compared to vaginal birth after cesarean (VBAC) deliveries in the United States, 1998-2002 birth cohorts. Maternal & Child Health Journal, 14(2), 147-154. doi:10.1007/s10995-009-0551-5 References Practice bulletin no. 115: vaginal birth after previous cesarean delivery. (2010). Obstetrics & Gynecology, 116(2 Pt 1), 450-463. doi:10.1097/AOG.0b013e3181eeb251Scott, J. (2011).

Vaginal birth after Cesarean delivery: A common-sense approach. Obstetrics & Gynecology, 118(2 Pt 1), 342-350. doi:10.1097/AOG.0b013e3182245b39 (Dickerson, 2010) Increased risk of morbidity with unsuccessful VBAC

Weak evidence of-
Fetal mortality
Intercranial hemorrhage
Asphyxia
Encephalopath/ cerebral palsy
Birth injury
Laceration
Infection Retrieved From: http://i.mommyish.com/wp-content/uploads/2013/03/shutterstock_127442771.jpg Retrieved from: http://babyladyoftheprairies.com/natural-childbirth-after-cesarean/ Retrieved from: https://healthy.kaiserpermanente.org/static/health-encyclopedia/en-us/pi/media/medical/hw/h9991303_001_pi.jpg (Grobman & Ecker, 2010) (Dickerson, 2010) (Dickerson, 2010) Nursing Implications Patient education and counsel if a TOLAC is not successful (Grobman & Ecker, 2010).
The nurse must inform the obstetrician of any abnormal labor patterns, poor fetal heart tones, and patient well-being (Dickerson, 2010). Nursing Implications 1. Identify risk factors
2. Interpret fetal monitoring tracing
3. Administer medications safely
4. Advocate for patient safety
5. Identify maternal clinical manifestations of uterine rupture (Davis, 2013) From L. Ryba Uterine Rupture A consistent sign of uterine rupture is fetal heart tone distress
Recurrent variable and late decelerations can be seen before bradycardia develops
The infant involved with uterine rupture can develop brain damage, intrapartum death, or death within a year of birth
(Dickerson, 2010) Retrieved from: http://www.registerednursern.com/wp-content/uploads/2009/01/late-decelerations.jpg American College Of Nurse Midwives
Position Statement (Grobman & Ecker, 2010) Women who have had a Cesarean delivery have the right to make an informed , evidence based decision when considering a TOLAC, VBAC or ERCD Continued Research What resources should be available at sites where women recieve obstetric services? (ACNM, 2011)
What clincial or policy interventions increase access to safe TOLAC? (AHRQ, 2012)
What barriers prevent access to a safe TOLAC including the outcome where physicians are "immediately available" as opposed to "readily available." (AHRQ, 2012)
What is the threat of legal liability on practices reagarding TOLAC vs ERCD? (AHRQ, 2012) ACNM Position Statement TOLAC is recommended as a safe option for the majority of women who have had a prior CD
Uterine rupture is the major risk of women who have TOLAC, however it is similar to the incidence of other obstetric emergencies
Approrpiate risk assessment and careful management of labor can reduce this risk
Women who desire large families and are candidates for TOLAC should be encouraged to attempt VBAC
(ACNM, 2011) Retrieved from: http://www.scienceandsensibility.org/wp-content/uploads/2012/07/ACNM-Logo.jpeg Retrieved from: http://www.nursemidwivesmn.org/ Retrieved from: http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp?urlhealthgate=%2214790.html%22 L. Ryba L. Ryba Retrieved from: https://www.healthtap.com/#topics/vbac Retrieved from: http://www.jacksonnursing.com/uploads/2011/07/thumbs-up-nurse.jpg Retrieved from: http://www.nurseduties.net/baby-nurse-duties/ Retrieved from: http://blog.parallonjobs.com/2013/03/18/how-do-i-become-a-per-diem-nurse/
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