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Homebirth VBACs & Abstracts about Pit and Home VBAC

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Homebirth VBACs

Personally, I consider homebirth VBACs safer than hospital VBACs, especially if the home is within a 20 minute drive to the hospital.

Many hospitals cannot really prepare for an emergency surgical delivery in less than 20 minutes. (Many people are surprised to hear that many hospitals do not actually have an obstetrician and anesthesiologist physically present at the hospital where they plan to labor. Unless it's a teaching hospital that has "residents", all the obstetricians are going about their lives, waiting to be paged. And, technically, those residents aren't really obstetricians yet. They can probably dig up an anesthesiologist from somewhere in the hospital, but haven't you noticed that when a woman wants an epidural, she often has to wait 15-45 minutes? They're not just standing around in L&D waiting to do an emergency section.)

So, if you can get to the hospital within 20 minutes of phoning to let them know you're transporting from a homebirth, you're probably protected just as well in the case of a sudden rupture.

In the case of slower ruptures, the one-on-one care provided by a trained midwife at a homebirth is significantly better than the care in most hospitals. Overworked hospital nurses "monitoring" the labor by occasionally glancing at one of many computer screens can often miss subtle signs of fetal distress. And they aren't in the room with the laboring mom to hear the first warning remarks about feeling a twinge of pain or a stitch in her side that happens to coincide with a change in the baby's heartrate pattern. And, once they do notice subtle problems, there's usually a back-and-forth over the phone before the OB is convinced to come to the hospital.

And, considering that most uterine ruptures are associated with pitocin, and pitocin is not used during labor at a homebirth, you're doing a lot to prevent a rupture.

The primary danger in homebirth VBACs is a legal one.

Abstracts about Pit and Home VBAC

Thank you for the informative post. I do have a question (and may get that question answered when I look up the Green Journal article), which is that in that article is there data collected on numbers of women who received oxytocin induction/augmentation related to rupture rate?

I don't have a copy of the article in front of me but I don't recall that they mentioned whether oxytocin was or was not used when there was a uterine rupture.

In the recent NEJM article (McMahon MJ et al. Comparison of a trial of labor with an elective second cesarean section. NEJM 1996;335:689-95), there were no data collected on this, only gross data on TOL and maternal and neonatal outcomes. It seems to me that this is a flaw, in general, and possibly occurring because induction/augmentation is such a common event in some areas. However, it would seem to me that a spontaneously occurring/normally progressing labour is quite different from one requiring induction/augmentation, especially in VBACs.

McMahon's article although limited as you point out. The conclusion of the study and I quote,

"Although the overall rate of maternal complications did not differ significantly between women who chose a trial of labor and the women who elected cesarean section (odds ratio for the trial-of-labor group, 0.9; 95 percent confidence interval, 0.8 to 1.1), major complications were nearly twice as likely among women undergoing a trial of labor (odds ratio, 1.8; 95 percent confidence interval, 1.1 to 3.0)"

I know that up here in the cold north, the SOGC is raising a red flag about the rupture rate in induced/augmented labours of VBACs. I think that, in order for us to understand what the rupture rates really are, we need to separate out these data for better consideration.

This is a valid point. One might guess that increasing the force of uterine contraction would subject the gravida to an increased risk of uterine rupture. This of course is confounded by the fact that oxytocin is used with failure to progress. Obstructed labor may be the real culprit, not oxytocin.

But even this does not pan out when you look at the literature. In constructing their opinion #64 that I previously posted, they cited 2 references (see below)

Horenstein and Phelan prospectively studied 732 patients. 289 received oxytocin for induction or augmentation. There were equal rates of dehiscence, 3% with oxytocin and 2% without (I will admit that these are somewhat higher rates than in other published papers.)

Flamm, et al. had 1776 patients of which 485 received oxytocin with no difference in uterine rupture.

So in committee opinion #64 they note:

"Because of the potential risk of uterine rupture with the administration of oxytocin, some physicians choose not to use it to induce or augment labor for patients who have undergone a prior cesarean delivery. Recent reports indicate, however, that the use of oxytocin for augmentation of labor confers no greater risk upon patients undergoing a trial of labor after prior cesarean delivery with low transverse incision than upon the general population"

More recent literature is summarized below:

Videla, et al. studied 713 patients. There were 588 TOLs with 517 VBACs (88% success!). There were 4 uterine ruptures only one of which occurred with oxytocin.

Raynor BD had 67 patients. 49% received oxytocin and 56% delivered vaginally. Two uterine ruptures occurred that were not associated with labor.

Additionally, there have been studies on cervical ripening with presumed uterotonic properties that show no increased risk of uterine rupture.

Clearly, uterine rupture occurs in the absence of augmentation. Even if the literature supported a twofold or higher increase in the risk of uterine rupture with augmentation, it would not remove the risk for naturally occurring labor.

I still do not waver in my opinion that home VBAC is a disaster waiting to happen. There is no safety net in place should this occur. ACOG standards are clear. When a uterine rupture occurs in a home TOL, if immediate cesarean is not accomplished within 30 minutes and adverse maternal or fetal outcomes result, violation of the standard of care is almost indisputable.


Oxytocin during labor after previous cesarean section: results of a multicenter study

Unique Identifier - 88014820

Authors - Flamm BL.  Goings JR.  Fuelberth NJ.  Fischermann E.  Jones C.  Hersh E.

Institution - Department of Obstetrics and Gynecology,

    Kaiser Permanente Medical Centers, California.

Source - Obstetrics & Gynecology.  70(5):709-12, 1987 Nov.

The use of oxytocin for labor induction or augmentation in patients with previous cesarean delivery is controversial. This paper presents a series of 1776 patients allowed to labor after a previous cesarean section, of whom 485 (27%) were treated with oxytocin. When the patients who received oxytocin were compared with those who did not, no significant differences were found with respect to uterine rupture, maternal morbidity, fetal morbidity, or fetal mortality. We conclude that the judicious use of oxytocin is safe in the patient with a previous low transverse cesarean section.

Previous cesarean section: the risks and benefits of oxytocin usage in a trial of labor

Unique Identifier - 85146036

Authors Horenstein JM.  Phelan JP.

Source - American Journal of Obstetrics & Gynecology.  151(5):564-9, 1985 Mar 1.

Permitting a trial of labor in patients with a previous cesarean birth is rapidly becoming an accepted alternative to routine elective repeat cesarean section. As interest in this approach has grown and the risks associated with a trial of labor have been better defined, the use of oxytocin in these patients emerges as a pertinent issue. Our retrospective experience of oxytocin use in patients undergoing a trial of labor suggested no increased maternal or fetal risk compared to patients who did not receive oxytocin. On the basis of our prior experience, we set out to investigate prospectively the role of oxytocin in 732 patients with prior cesarean section who underwent a trial of labor. During the study period, 289 (40%) patients received oxytocin for either induction (32, 11%) or augmentation (257, 89%) of labor and 443 patients did not receive oxytocin. Successful vaginal delivery was achieved in 200 patients (69%) as opposed to 395 (89%) of the patients who did not receive oxytocin. The incidences of dehiscence in the oxytocin and no oxytocin groups were 3% and 2%, respectively. Further analysis of vaginal and cesarean delivery complications for the two groups were contrasted and no significant differences were found with respect to the incidence of hemorrhage, uterine atony, hysterectomy, or the requirement of transfusions. Neonatal outcome was also comparable for both groups. On the basis of our prospective experience, it appears that the use of oxytocin, when carefully monitored, is a safe and reasonable consideration in the patient undergoing a trial of labor.

Cervical ripening and labor induction after previous cesarean delivery

Unique Identifier - 96040017

Authors - Chez RA.

Institution - Department of Obstetrics and Gynecology, University of South Florida,

    College of Medicine, Tampa 33606, USA.

Source - Clinical Obstetrics & Gynecology.  38(2):287-92, 1995 Jun.
Abstract The preponderance of published data derived from TOL/VBAC patients indicate that (1) if there is no contraindication to spontaneous cervical ripening, there is no contraindication to use of prostaglandin gel or tents to ripen the cervix; and (2) if there is no contraindication to the spontaneous onset of labor, there is no contraindication to use of oxytocin or amniotomy to induce labor. Both conclusions are based on the assumption that treatment and care is provided in a safe, modern obstetric service with staff and resources compatible with national standards. [References: 45]

Trial of labor: a disciplined approach to labor management resulting in a high rate of vaginal delivery

Unique Identifier - 95336533

Authors - Videla FL.  Satin AJ.  Barth WH Jr.  Hankins GD.

Institution - Department of Obstetrics and Gynecology, Wilford Hall Medical Center,

   Lackland Air Force Base, Texas 78236-5300, USA.

Source - American Journal of Perinatology.  12(3):181-4, 1995 May.
Abstract A disciplined approach to labor management has resulted in a low cesarean rate (9%) in our population. We wondered if this management scheme was applicable and safe applied to women with previous cesareans. Women with a previous cesarean delivering in a 5-year period were included. Labor management included encouragement of trial of labor, labor stimulation with oxytocin when indicated, epidural analgesia only after entering the active phase, and continuous monitoring. Demographic, labor and delivery, and neonatal data were electronically stored and analysis performed using SPSS release 4.1 for VAX/VMS. Statistical analysis was performed using chi-square and Fisher's exact test where appropriate. Multiple logistic regression was performed to control for potentially confounding variables. A previous cesarean had been performed in 713 (11%) gravidas who met the inclusion criteria. Vaginal delivery was attempted in 588 (82%) and 517 (88%) achieved vaginal birth. Older women (14 versus 1 versus 8%, p = 0.04), of higher parity (63 versus 35 versus 17%, p = 0.0001), requiring preterm delivery (14 versus 8 versus 4%) were more likely to have an elective repeat cesarean than a successful or failed trial of labor. Pregnancies requiring oxytocin (90 versus 53%, p = 0.02), receiving epidural analgesia (62 versus 49%, p = 0.05), developing chorioamnionitis (20 versus 4%, p < 0.0001) were more likely to fail a trial of labor. Four uterine ruptures occurred and only one patient was receiving oxytocin. There were no differences in umbilical artery blood acidemia among elective repeat cesarean sections and successful or failed trial of labor.

The experience with vaginal birth after cesarean delivery in a small rural community practice

Unique Identifier - 93128412

Authors - Raynor BD.

Institution - Rural Health Group, Roanoke Rapids, NC.

Source - American Journal of Obstetrics & Gynecology.  168(1 Pt 1):60-2, 1993 Jan.

OBJECTIVE: The purpose of this study was to determine if the success and safety of vaginal birth after cesarean delivery in a small, isolated, rural hospital compare with those seen in larger centers.

STUDY DESIGN: As part of a continuing study, the prenatal and hospital records of all patients with previous cesarean delivered by the Rural Health Group between October 1988 and January 1991 were reviewed. Patients were allowed a trial of labor with one or more previous cesarean sections, unknown scar, and breech presentation but not for other malpresentation or a vertical scar.

RESULTS: A total of 67 patients were studied; 76.1% of these had a trial of labor, and 60.8% of them were delivered vaginally, whereas 39.2% underwent repeat cesarean delivery. Of the 67 patients 11.9% were not candidates for vaginal birth after cesarean delivery, and the same percentage refused. Forty-nine percent received oxytocin; of these, 56% were delivered vaginally. Overall, maternal complications were similar between the groups. Two uterine ruptures occurred; neither was associated with labor. The major maternal complications occurred in the vaginal birth after cesarean delivery group, but all were associated with antepartum conditions and not related to labor and delivery. There were no maternal deaths. The only neonatal death resulted from a congenital anomaly.

CONCLUSION: We concluded that vaginal birth after cesarean delivery can be performed safely in an isolated small community hospital with success rates similar to those of larger centers and with no increased maternal or neonatal morbidity or mortality.

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