Trial of Labor After Cesarean Section

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1 Trial of Labor After Cesarean Section 1 After you have a baby by cesarean section, you can choose how to have your next baby. You can choose to schedule another cesarean section ( scheduled repeat cesarean section ), or you can choose to have a trial of labor after cesarean delivery. Unless there are complications with the pregnancy, a scheduled cesarean section is not scheduled until you are at least 39 weeks pregnant, or one week before your due date. TOLAC is a Trial of Labor After Cesarean Section. For women who are good candidates for a TOLAC, 60-80% succeed and give birth vaginally (have a VBAC). VBAC is a Vaginal Birth after Cesarean Section-when the TOLAC successfully leads to a vaginal birth. You may not be a safe candidate for a TOLAC depending on the type of incision that was made on your uterus. The type of incision on your uterus may not match the type of incision on your skin. We will need to review the operation report from your last cesarean section to decide if you are a candidate. TOLAC is not the right choice for everyone, but it is a good option for many women. It is important for you to understand the risks and benefits of attempting a TOLAC versus choosing a scheduled repeat cesarean delivery. Each woman has slightly different risk factors and chances of success and we will discuss your specific situation with you. To safely attempt a TOLAC and VBAC, chances of success should be as high as possible. While no one can perfectly predict your chances of success, there are certain factors that increase and decrease your chances of success. One tool to predict your chances of success is: Using this tool and your doctorsʼ clinical judgement, if you are estimated to have at least a 60-70% chance of having a VBAC, it is reasonable to choose to have a TOLAC. If your estimated chances of success are less than 60%, a repeat cesarean section would be the safest option for you. Your chances having a successful TOLAC decrease once you go past your due date. If you have not delivered, we will schedule you for a repeat cesarean section no later than one week past your due date if you have had one prior cesarean section. If you have had two prior cesarean sections, the risk of the uterus rupturing is twice as likely (1.8% instead of 0.9%); the risk is still low enough for otherwise good candidates to have a TOLAC. However, because the risk is increased, we are only comfortable safely offering TOLAC to women who have had two prior cesarean sections when: Your estimated chance of success is at least 60%. You have not failed a TOLAC in the past

2 2 You labor spontaneously by your due date. We will schedule a repeat cesarean section no later than your due date. For women with a prior cesarean delivery, there are three possible outcomes: 1. Vaginal Birth After Cesarean Section (VBAC)-a successful trial of labor-this situation has the lowest risk of complications for the mother and baby 2. An unsuccessful trial of labor resulting in cesarean delivery-this situation has the highest risk of complications for the mother and baby 3. An elective repeat cesarean delivery The risk of a mother or baby dying related to childbirth is extremely low. The risk is slightly increased for the mother in an elective repeat cesarean and slightly increased for the baby in a TOLAC, but the overall risks for either situation are extremely low. TOLAC Elective Repeat Cesarean Other comparison 4 Maternal deaths per 130 baby deaths first 28 days of life per 13 Maternal deaths per 50 baby deaths first 28 days of life per 100,000 live births 16 (Motor vehicle deaths/100,000 US men and women population 677 all causes of baby deaths first year of life per 100,000 live births A serious risk of a TOLAC is uterine rupture, or a tear in your uterus. The risk of this is low ( %). This means that for every 100 women having a TOLAC, about one woman will have a uterine rupture. When this happens it can be a serious threat to the life and health of the mother and baby. When the uterus ruptures, the mother is at risk of serious bleeding requiring transfusion, damage to organs such as the bladder, and 14-33% will need a hysterectomy. When the uterus ruptures, 3-6% of babies will die or suffer brain damage. A serious risk of elective repeat cesarean section is that multiple surgeries can put future pregnancies at risk. Multiple cesarean sections increase the risk of placenta problems like placenta previa (placenta growing over the cervix) or placenta accreta (placenta growing into the wall of the uterus). These problems are associated with a significant risk for preterm delivery, bleeding requiring transfusion, hysterectomy, and injury to organs such as the bladder. Each additional cesarean section further increases these risks.

3 3 Risks and benefits of TOLAC and repeat cesarean section include but are not limited to: Risks of TOLAC Benefits of TOLAC The normal risks of vaginal birth Uterine rupture TOLAC may not succeed so you may need a cesarean section A cesarean section after labor has more risk of infection and surgical injury than an elective cesarean section Increased risk of infection in the baby Increased risk of baby dying or having brain damage (extremely low risk) No abdominal surgery Shorter recovery period Lower risk of infection Less blood loss In women planning more children, avoiding problems linked to multiple cesarean deliveries Less risk the baby will have short term breathing problems Risks of Elective Repeat Cesarean Section Surgical risks (Bleeding, infection, injury to surrounding organs such as bowel and bladder, Blood clots) Multiple cesarean sections increase risk for future pregnancies Increased risk of short term breathing problems for the baby Increased risk of mother dying (extremely low risk) Benefits of Elective Repeat Cesarean Section Planned delivery date Less emotional toll than emergency cesarean section Lower risk of uterine rupture and its risks

4 4 My specific risk factors may change during the pregnancy. I understand the factors that I have that increase and decrease my chances of a successful TOLAC (circle all factors that apply). Factors that increase my chances of VBAC age<40 BMI<30 estimated fetal weight <8 # 13 oz gestational age <40 weeks prior vaginal births prior VBAC spontaneous labor reason for previous cesarean section favorable cervical exam Factors that decrease my chances of VBAC age > or = 40 BMI> or = 30 estimated fetal weight >8# 13 oz gestational age > or = 40 weeks no prior vaginal births reason for previous cesarean section unfavorable cervical exam Short time between deliveries(<18 months) Preeclampsia Based on the prediction tool: My estimated chance of success My risk of uterine rupture 0.9% (one prior cesarean section) 1.8% (two prior cesarean sections) NOTES If I choose a TOLAC: Because problems may arise during labor such as the baby not tolerating labor or labor not progressing, the my baby may need to be born by cesarean section. This may be an emergent situation. For the safety of me and and my baby, I agree to placement of an IV catheter and continuous monitoring of the baby. We share the same goal: a healthy baby delivered to a healthy mom. Mission Hospital has anesthesia, operating room staff, and doctors for the mother and baby at the hospital 24 hours a day. This may lower the risk to the baby if there is a uterine rupture (tear in the uterus) but not in all cases. There is a risk associated with every pregnancy no matter what type of delivery is chosen and that risk can never be completely removed. I choose (circle one) Scheduled Repeat Cesarean or Trial of Labor After Cesarean Patient Printed Name Provider Printed Name

5 5 Patient Signature Provider Signature

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