VBAC

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Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

Birth Planning for Women with a Prior Cesarean Section
**Terminology:** **VBAC**: Vaginal Birth After Cesarean **VTOL:** Vaginal Trial of Labor **TOLAC:** Trial of Labor after Cesarean Contra Costa Regional Center Perinatal Unit encourages vaginal birth after cesarean delivery and is committed to making the option safe for mother and baby for women who are candidates for vaginal delivery. We make recommendations regarding route of delivery based on uterine rupture rate, expected success rate, and maternal preference. We have safety measures in place to recognize the rare uterine rupture and to intervene rapidly. Mothers also maintain the option of a repeat elective cesarean. __**Expectations of Prenatal Care**__
 * Review obstetric history for accuracy.
 * Verify gestational age of prior births and incision type on cesareans.
 * Obtain records when possible and especially for preterm or complicated cesareans.
 * Review records of prior births at CCRMC.
 * Review for complications of vaginal delivery such as shoulder dystocia that might favor repeat cesarean as the better option.
 * Put H/o Cesarean on the problem list and pertinent details in the overview
 * Assess whether VBAC is an option (see below)
 * Discuss option of VBAC and put preference in problem list e.g. "Desires VBAC" or "Requests repeat cesarean" Keep in mind circumstances at the end of the pregnancy such as fetal position, estimated fetal size, need for induction, or presenting in advanced labor may change the intended plan.
 * In Star Icon forms under OBGYN patient handouts find the VBAC patient information pamphlet and a copy of the consent. Provide both to patient who is candidate for VBAC. Consent will be signed on Labor and Delivery and this allows her to read it in advance.
 * Consult with OB Dept member whenever necessary. It is reasonable to send your patient for a consult visit to a Prenatal Clinic with a physician who delivers for further discussion.

__**VBAC is Contraindicated**__ 1. Prior incision in the contractile portion of the uterus rather than the usual low transverse uterine incision –in the US the incision up into the contractile portion is called a "classical cesarean" (in Mexico incision classico is a low transverse incision). This is NOT related to direction of skin incision. This is most common for preterm (< 32 weeks) breech babies, or complicated fetal lie/fibroids. This situation is similar to prior myomectomy that enters the uterine cavity or prior cornual ectopic surgery on the horn of the uterus. Uterine rupture rate is about 10% and repeat cesareans are scheduled early at 37 weeks—consult for delivery plan if you find this situation (prior classical incision, prior T incision, prior myomectomy, prior cornual ectopic). 2. Three or more prior cesarean sections—the rate of uterine rupture and the difficulty of an emergent rescue surgery become prohibitively dangerous __**VBAC is not recommended at CCRMC**__ 1. No prior vaginal deliveries AND two prior cesarean sections (may be appropriate candidate for VBAC if strongly desired, prior indications for cesarean not recurrent, and presents in spontaneous labor) 2. No vaginal deliveries AND induction of labor with an unfavorable cervix needed (this is due to lower success rate < 50% and slightly higher uterine rupture rate) 3. Less than 6 months from cesarean to conception of current pregnancy 4. Prior cesarean < 32 weeks and records not available to verify low transverse uterine incision Other Common Questions
 * Yes, do a GBS swab if elective cesarean is planned. This is helpful to pediatrics if labor or rupture of membranes before the cesarean. Occasionally a patient planning a repeat cesarean will present in labor and decide on VTOL.


 * Treat anemia as a good Hb is helpful for both VBAC and repeat cesarean


 * Repeat cesareans are scheduled for sometime after 39 weeks EGA. Please make sure that dating is correct and that she is at least 39w0d by all reasonable dating criteria. She will be sent home if 38w6d.


 * Prior classical incision, myomectomy or other obstetric issues might indicate an earlier cesarean—consult when this is suspected.