TOLAC and VBAC and Rupture! Oh My!

by, Bree Fallon

As a brand new labor nurse fresh out of school, I distinctly remember visiting with a seasoned traveling nurse, Pam Spivey, during an afternoon of monitoring women on the antepartum unit years ago. One of the preterm women I was caring for that afternoon was planning to attempt a vaginal birth after cesarean (VBAC) with this pregnancy when the time came.  I was pretty green and knew what the acronym stood for, and that was about it. Pam and I began to converse about VBAC and she shared a story of hers from years prior.

She told me about a woman who had been admitted to L&D. The woman had delivered her previous baby in another country by C-section and the plan for her was to allow a trial of labor after cesarean (TOLAC). Pam said her labor progressed beautifully and soon it was time for her to push. I leaned forward on the edge of my seat as Pam recounted the details. She called the provider to come for delivery. “The fetal head crowned up so nicely, and then it was gone!” I felt my eyes grow large. “Where did it go, Pam?!” I thought. She explained the next moments were a mad dash. She pulled all of the cords and plugs out of all of the devices and outlets, grabbed the nursery nurse and down the hall they went with the woman in the bed, snagging the physician on the way as they ran to the OR. Pam even remembered losing her shoe along the way to the OR, but she did not slow down. Confused, I sat in disbelief of this story. Pam recalled the team got the woman to the OR, rapidly delivered her baby via C-section, and both mom and baby survived the ordeal and did well. Still perplexed, I asked out loud this time, “Where did the head go, Pam?” The kind nurse looked at me and explained when a woman’s uterus ruptures, there is no pressure inside the uterus or on the baby anymore. The instant that the head was gone, Pam knew the woman had ruptured her uterus and the lives of both mom and baby were at stake. Horrified, I logged this story away in my brain, vowing to remember what to do when this happened while I cared for a woman.

My first year flew by. Plagued by a horrible cloud of bad luck that followed me on and off of my floor daily, whenever I saw my name assigned next to a woman attempting VBAC, I would swallow the lump in my throat, and Pam’s story would flash in my head. I would mentally prepared myself, ensuring I had my A game for this woman, should any signs or symptoms of uterine rupture arise at any point in the day. The woman would either be successful in delivering vaginally or would not be successful. The only thing that mattered to me at the end of the day was healthy baby, healthy mommy.

A couple years later, my very best friend in the world and an exceptional labor nurse, Kelsey, was pregnant with her first baby. Her baby was breech and was delivered by cesarean. I remember Kelsey laying behind the drape, asking for updates, if her baby girl was ok. Having the privilege of caring for her sweet infant in the OR that day, I swaddled her newborn up as fast as I could. Kelsey had already waited 9 months to meet her daughter, so the extra few moments it took for me to wrap the baby and hand her to Kelsey’s husband before Kelsey could even see her seemed cruel. They snuggled with their new little one while doctor finished the surgery. In the PACU, Kelsey felt pukey and could not hold her infant. Recovery was not easy, but she didn’t know any different. Still today, Kelsey remembers having a difficult time bonding with her infant, and wonders if her delivery by cesarean had anything to do with it.

With Kelsey’s second baby, after discussing the risks and benefits with her provider, Kelsey wanted to attempt VBAC. I was very hopeful for her, but sick to my stomach a little too. Remembering Pam’s story, I was incredible apprehensive and ultimately didn’t want anything bad to happen to Kelsey. Her pregnancy flew by and was induced at 39 weeks and 5 days. I raced to the hospital with the very important job of taking pictures. Kelsey’s labor progressed and she delivered quickly with no complications. Watching my best friend get to see her baby immediately and hold and soothe her right away is one of my most favorite memories of my career. I had taken care of many women who had successful VBAC, but did not really understand its significance until seeing first hand Kelsey and her husband experience both types of delivery.  Never having a cesarean myself, but circulating hundreds, I considered them routine. It was very powerful for me to see the difference between a vaginal birth and a cesarean for the same woman.

Just this week I was asked to review some literature to develop patient education on VBAC. Here are a few facts that stuck out to me taken from ACOG Committee Opinion 342 as well as ACOG VBAC Guidelines.

• 60-80% of appropriate candidates who attempt VBAC will be successful. The odds are in your favor that a woman will have a vaginal birth.

• The risks for both elective repeat cesarean and TOLAC include maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. Both have their risks.

• Overall benefits for a VBAC is avoiding major abdominal surgery. This lowers a woman’s risk of hemorrhage and infection, and shortens postpartum recovery too.

• The most maternal injury that happens during a TOLAC, happens when a repeat cesarean becomes necessary if the TOLAC fails. Maternal injuries can include uterine rupture, hysterectomy, or even death.

• There are risks for baby too. Both elective repeat cesarean delivery and TOLAC neonatal complications can include admission to the NICU, hypoxic ischemic encephalopathy, and even death. One study found the composite neonatal morbidity is similar between TOLAC and elective repeat cesarean delivery for women with the greatest probability of achieving VBAC.

• If a woman has had a prior vaginal birth or goes into labor spontaneously, she has an increased probability of successful VBAC.

• If a woman had an indication for her initial cesarean that may reoccur with subsequent labors such as labor dystocia or arrest of descent, she has a decreased probability of successful VBAC. If a woman  is of non-white ethnicity, is more than 40 weeks gestation, is obese, has preeclampsia, has a short interval between pregnancy or increased neonatal birth weight, her probability of successful VBAC is also decreased.

• Women pregnant with twins attempting VBAC have similar outcomes to women with singleton gestations and did not have a greater rate of rupture or perinatal morbidity. (I have never had a twin mom attempt VBAC but it can be done!)

• On the topic of induction, one study on 20,095 women attempting VBAC found a rate of uterine rupture of 0.52% with spontaneous labor, 0.77% for labor induced without prostaglandins and 2.24% for prostaglandin-induced labor. Prostaglandins should be avoided in the third trimester in women who have had a previous cesarean section.

As years went by, I cared for more women who wanted a vaginal birth after cesarean. I cheered hard for each of them to be able to experience a vaginal birth. Any healthy birth is always a miraculous moment to have the privilege to be a part of. However, caring for women who had only experienced a cesarean before the days of skin-to-skin in the OR and then watching them birth vaginally, and being able to instantly see, touch, hold their infant, is priceless.

In my 12 years of bedside care I worked in facilities delivering on average 4,000- 5,000 babies a year, and a uterine rupture during labor had never happened to one of the women in my care  I was in charge once where one of the nurses correctly identified that the scar on her patient’s uterus was beginning to pull apart. The woman had a cesarean immediately and delivered a healthy baby without any complications. We have had cases of uterine rupture since on my floor. It can happen and if it happens, it becomes an emergent situation that must be resolved swiftly and seamlessly for a good outcome. However, it doesn’t happen very often. In fact, ACOG cites the risk for uterine rupture for woman attempting TOLAC is low, between 0.7-0.9%.

There are many indications where a cesarean delivery is absolutely necessary. In the case of an elective repeat section or a TOLAC, it is imperative that women review the risks and benefits of both with their provider to ensure they make the right choice and promote  a healthy, happy mom and a healthy, happy baby.

Bree Fallon, BSN, RNC-OB, C-EFM
Bree Fallon is a Clinical Educator for Perinatal Services at Shawnee Mission Medical Center, the busiest delivering hospital in Kansas City. She graduated from nursing school in 2004 and started her career in a tertiary care facility, providing high risk intrapartum and antepartum care. In 2010, she moved to Children’s Mercy in Kansas City who was looking for experienced L&D nurses to help open the their new Fetal Health Center.