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TOLAC vs. elective repeat cesarean delivery

Any scar tissue is weaker than original tissue, but can usually carry the function of the organ. With past hysterectomy the uterus is weakened by the surgical cut; increasing the risk uterine rupture during labor (when the uterine muscles work hard to push the fetus though the birth canal).

The consequences of such event can be catastrophic for both the mother and the baby; prompting obstetricians to recommending elective cesarean section to their patients.

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Cesarean section, even when scheduled ahead of time, is still a major abdominal surgery; putting patients at risk of complications such as lacerations of the intestines and bladder, infection, hemorrhage, development of DO and pulmonary embolism. Post surgical adhesions can result in bowel obstructions, infertility, organ displacements and pain.

Through years of research, it has been proven that babies delivered via C-section are at increased risk for respiratory complications and NICE stays (Kamala, 2009). Mothers considering elective repeat cesarean should be aware that multiple scars on the uterus can complicate future pregnancies resulting in conditions such as placenta Prevail and placenta accurate. Multiple hysterectomies (cut though the uterus) increase the risk of necessary hysterectomy (removal of the organ) during or even after the surgery.

Because the risks increase with each consequent cesarean, mothers delivering via this method should be educated about possible limit on the number of future pregnancies (London, 2011; AGOG, 2010) Despite the dangers associated with repeat cesarean, supporters of this method argue that the risks associated with elective surgical delivery are lower than those associated with emergency c-section following uterine rupture . Because of the restrictions on the TOTAL candidates as well as limited interventions augmenting delivery during TOTAL, for many mothers repeat cesarean is the only safe option of delivering her baby.

TOTAL / ABACA In the late ass’s of last century an increasing number of cesarean deliveries prompt the National Institute of Health and American College of Obstetrics and Genealogy to encourage B providers to allow woman with prior Cesarean an option for vaginal earth. TOTAL has since become a popular choice; increasing in numbers up to mid ass’s; reaching 28% in 1996 ( AGOG, 2010). ) To some mothers natural delivery is a very important aspect of welcoming a baby to the world.

Among the advantages of successful ABACA, shortened hospitals stay and greatly decreased recovery times often are important considerations for mothers who already have one or more children in the house. Natural offset of labor often is associated with developmental readiness of the fetus and results with lower NICE stays. Passing through the birth canal pushes he fluid out of the baby’s lungs easing the first breaths and decreasing respiratory distress. Natural labor stimulates production of colostrums and speeds up secretion of milk, allowing newborns a better nutritional start (London, et. All, 2011).

Careful selection of candidates for TOTAL decrease the dangers associated with this option, but serious risks for both mother and baby remain. As Mentioned earlier uterine rupture is among the worse case scenarios, granting the need for emergency cesarean section. Health research established that the risk of uterine tear or rupture upends on the kind of incision(s) previously performed on the uterus. The classic hysterectomy is associated with the greatest risks of rupture during labor. This kind of incision was popular in the past and consisted of high vertical cut though the fibers of the upper part of the uterus.

Low vertical hysterectomy is similar to classic incision, but take place in the lower non portion of the uterus, resulting in fewer risk of rupture during future labor, however because the incision cuts through the number of fibers in the uterus (vertical cut through the horizontally align smooth muscles of uterus) the risk is still greater than the low transverse incision. The latest one, being the safest and most commonly performed nowadays (certain situations however prompt the B provider to use vertical or other incisions of the uterus, those may include: emergency, multiple gestations, unfavorable position of the fetus).

Because the superficial cut though the skin may not match the direction of the hysterectomy, adequate review of the patient documentation form the previous deliveries is necessary to assure patient’s safety during trial of labor. Vertical incisions almost always grant the patient the need for the repeat cesarean ( London, et all, 2011). Because of the real risk of uterine rupture, mothers attempting TOTAL should be closely monitored during labor; external monitors should be attached to continuously observe frequency of contractions and fetal heart rate.

Rapid change in the fetal heart rate, combined with the loss of contraction on the monitor may be associated with the tear in the uterus. Certain medications and procedures may increase woman’s risk of uterine rupture: inducing labor with Piton or certain prostaglandin s among such actions therefore limiting Total’s to spontaneous offset of labor. Delivering the baby past its due date is associated with larger babies; increasing the strain on the weakened uterus. (Guise, et. Al, 2010) In addition to the presence of the favorable horizontal uterine incision, mothers should meet other recommended criteria to have the greatest chance of successful TOTAL: pelvis appropriate for delivery, body weight less than 200 lbs and favorable fetal position at the time of delivery along with lack of overall health conditions (diabetes, hypertension Just to name a few)(AGOG, 2010). It is thought that previous vaginal delivery (whether before the C-section or ABACA) greatly increases the chances for successful vaginal delivery, while lack of such experience may sway the providers away from TOTAL.

A provider’s personal experience with TOTAL may also play a role when choices regarding delivery are discussed. CONCLUSION Despite the benefits of ABACA and the reduced medicals risks that have come with advancement in the field, ABACA deliveries are on the decline from their high. “[sic] however, medico-legal issues and concerns about the risk of uterine rupture have undistributed to a reversal in this trend” (Angstrom, 2011) and in 2006 only 8. 5% of woman successfully gave vaginal birth after previous c-section experience (AGOG, 2010).

Nowadays less than 10% of mothers chooses TOTAL over elective cesarean, between 60 and 80% of them will successfully deliver their baby vaginally (ABACA). Despite great chances for successful outcomes of TOTAL many facilities and providers don’t offer their patients an option for TOTAL, pressing the expecting mothers for elective surgery. This may have been the result of earlier strict recommendations released by the AGOG in the ass’s which requiring facilities offering TOTAL to have ability of performing emergency cesarean sections on woman with failed TOTAL dames, 2010).

Despite recent loosening of those strict requirements in August of 2010 many hospitals still offer repeat cesarean as the only option available. Attempting TOTAL in facilities that are not equipped for emergent situations seems very risky, as labor may quickly change its direction and put the mother and her baby at risk (situation that may arise during any labor). Additionally, attempting TOTAL at facilities that start offering it due to a change in recent recommendations seems also to favorable for the mother; as those facilities lack personnel trained and accustomed to the care of laboring woman with a history of cesarean.