TOLAC

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Contents

Candidates
  • [***] 1 previous LUTC/S (Level 1) (rupture rate ~0.7%)
  • [***] 2 previous LUTC/S (Level 2) (rupture rate ~0.9%)
  • [***] Unknown uterine scar unless likely Classical (Level 2) (rupture rate ~0.9%)
  • [***] Twin Vaginal delivery for women with 1 LUTC/S (Level 2)
  • [***] Prior Low Vertical rupture rate ~2.0%(ACOG)
Contraindiciations
  • [***] Prior classical or T-Shaped Incision (rupture rate ~2.0% & higher)
  • [***] Extensive Fundal surgery / Fibroid Surgery into Myometrium
  • [***] Previous rupture
  • [***] Prior Low Vertical (rupture rate ~2.0%)(utdol & AAFP)
Success Calculator
Consent
  • [***] Discuss future fertility plans (# of children desired)
  • [***] Discuss IPI / pregnancy spacing
  • [***] Complications increase significantly after 3rd Cesarean delivery
  • [***] LAC/VBAC Outcome Chart
  • [***] Risks, benefits, alternatives, and indications discussed with mother for TOLAC/VBAC. Discussed that some outcomes are better for mothers, some outcomes better for babies in each type of delivery. General statistical trends exist but we're unable to translate it to individual patient outcomes. Risks including bleeding, infection, damage to organs if Cesarean Delivery (CD) needed. Increased morbidity for mother & baby if CD needed after TOLAC. Discussed rare need for Cesarean-Hysterectomy and blood tranfusions. Relative & absolute risks for both are hard to identify and we can't predict who will have what outcome. All questions are answered.
Antenatal Monitoring
  • [***] Consider growth U/S @ 36 weeks w/ 250g / week to assess fetal size
  • [***] Membrane Stripping @ 38 weeks on a weekly basis to reduce need for IOL / time to spontaneous labor
Antepartum Care
  • Rescore patient on labor presentation with Antepartum Success Calculator
  • Labor induction to be avoided, except for medical reasons
    • Foley Catheter (rupture risk minimal)
    • Low-Dose Oxytocin (Pit I) (rupture risk ~1.1%)
    • Cervidil (rupture risk ~2%)
    • Cytotec (rupture Risk ~13%)
  • Labor augmentation may be ok with Low Dose Oxytocin (Pit I)(<20)
  • Epidural for anesthesia may be a reasonable suggestion
References
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