CCI Institute for Excellence: Labor and Delivery after Cesarean Section in Small and Large Hospitals
The Rising Popularity of TOLAC/VBAC: Factors and Implications
Trial of labor after Cesarean (TOLAC) and the resulting vaginal birth after Cesarean (VBAC) have been a practice in obstetrics for several decades. Recently, the practice has become more common and is shifting to smaller and more rural hospitals. This increase in the popularity of TOLAC/VBAC is multifactorial. However, three main factors are leading to increased pressure for TOLAC/VBAC. First, patients are requesting TOLAC/VBAC as a more “natural” way to have children after a Cesarean delivery. Second, changes in reimbursement and coding have put financial pressure on providers and facilities alike to move toward more TOLACs/VBACs. Finally, multiple studies have described the relative safety of these techniques, which has led to greater acceptance of TOLAC/VBAC at smaller and smaller facilities. This article will begin with a more in-depth description of these three factors.
Guidelines and Practical Advice for Implementing TOLAC/VBAC Programs in Smaller Facilities
We will then provide the guidelines for TOLAC/VABC from the American College of Obstetrics and Gynecology (ACOG), the American Society of Anesthesiologists (ASA), the American Association of Nurse Anesthesiology (AANA) and UpToDate. Finally, we will provide practical advice on 1) whether a facility is equipped and appropriate for TOLAC/VBAC patients and 2) how to best design a program and develop ancillary services to safely and efficiently treat TOLAC/VBAC patients at a facility.
Understanding the Benefits and Financial Incentives
While not the focus of this article, a short description of the reasons for increases in TOLAC/VBAC is necessary. The requests for TOLAC/VBAC have risen steadily in concert with the rates of Cesarean sections, but more so in the last 10–15 years. VBAC has myriad clinical benefits. First, avoiding major abdominal surgery decreases short and long-term complication rates of bowel adhesions, wound dehiscence, hemorrhage, DVT, and infection. Shorter recovery rates are a benefit, as well. However, a major factor contributing to more requests for TOLAC/VBAC is the parturient’s mental and emotional well-being and the “natural labor” movement. Clear benefits exist to vaginal delivery, most of which are improvements in the baby’s physical functions immediately after birth. Additionally, many mothers find vaginal delivery to be less mentally and emotionally detrimental, particularly if the first Cesarean delivery was urgent, emergent or an experience in which they felt a high level of fear or anxiety. Second, as is common in the current medical environment, cost and reimbursement play a critical role in pressures to perform (or not perform) certain procedures. There has been a steady increase in reimbursement rates for TOLAC/VBAC on both the facility and provider side in the last twenty plus years. While not the primary factor, clearly, this financial incentive has pushed facilities and providers alike to look for more and safer ways to conduct TOLAC/VBAC on more patients. This pressure has had a positive effect on patient selection and screening, facility preparedness, and protocols for safe TOLAC/VBAC.
The Importance of Patient and Facility Selection
The multiple studies conducted on TOLAC/VBAC have provided evidence of the high level of safety and success when appropriate patient selections and facility support services are in place. Overall, the rates of serious complications to the mother for all comers for TOLAC/VBAC is between 5% and 7%, while that for those undergoing repeat Cesarean section is approximately 4.8%. Similar rates exist for complication rates of the neonate between the two techniques. Additionally, TOLAC/VBAC only carries with it a small increased risk of complications as compared to vaginal delivery in parturients with no previous Cesarean section. While some of this safety profile is likely due to the inherent safety of TOLAC/VBAC and the delivery process in the United States, much of the safety is likely due to proper patient and facility selection, which leads into the next portion of this article.
Key Patient Selection Criteria and Contraindications
One critical issue that has allowed less morbidity and mortality to mothers and neonates undergoing TOLAC/VBAC is patient selection. Much of the data on patient selection is drawn from the obstetric (ACOG) literature. However, anesthesia providers must be a part of the decision making process when caring for parturients hoping to deliver via TOLAC/VBAC. The ASA and AANA have endorsed these recommendations as well. The ACOG article will be available in the Chiefs’ Folder for CCI providers to review. Listed below, in bullet format, are the key patient selection criteria:
- One (1) previous Cesarean delivery (not more than one)
- Previous low transverse incision
- No history of placenta accrete
- BMI less than 40
- Single fetus gestation
- Previous cause of cessation of labor not repeated in current pregnancy
On the other end of the spectrum are the relative and absolute contraindications for TOLAC/VBAC.
- Multiple previous Cesarean deliveries (two or three previous – relative contraindication, more than three previous – absolute contraindication, although there is some debate)
- Macrosomia (relative contraindication)
- Gestation beyond 40 weeks (relative contraindication)
- Previous low vertical incision (controversial, but likely a relative contraindication)
- Twin gestation (relative contraindication)
- Triplet or more gestation (absolute contraindication)
- Obesity (relative contraindication)
- Super morbid obesity (absolute contraindication, with some debate)
- High risk of uterine rupture (absolute contraindication, with some debate)
- Home birth or birthing centers (absolute contraindication)
As a side note, method of anesthesia or analgesia does not have any negative effect on TOLAC/VBAC. Specifically, despite the early literature, epidural analgesia does not result in occult uterine rupture or a more likely repeat Cesarean section.
Essential and Highly Recommended Resources for TOLAC/VBAC Facilities
Finally, the facility at which the TOLAC/VBAC is occurring MUST have a basic level of resources. These absolutely necessary resources include:
- Clinicians capable of monitoring labor and performing immediate emergency Cesarean birth
- Clinicians capable of providing obstetric anesthesia for emergency Cesarean birth
The highly recommended resources include:
- Pediatric clinicians and NICU capabilities
- An open and staffed operating room
- Ancillary staff trained in TOLAC/VBAC care
As an important note, two main resources are explicitly NOT required:
- In house anesthesia providers
- Anesthesia provider qualifications (anesthesiologist vs. CRNA).
Finally, each state may have its own specific statutes for TOLAC/VBAC. Each facility may have differing bylaws.
While not a comprehensive list or article, we hope this brief review and article will be helpful as you manage OB services conducting TOLAC/VBAC.
- Vaginal birth after cesarean delivery. ACOG Practice Bulletin No. 205. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e110-127.
- Guidelines for Neuraxial Anesthesia in Obstetrics. (Approved by the American Society of Anesthesiologists House of Delegates on October 12, 1988 and last amended on October 17, 2018)(and Submitted for update House of Delegates October 13, 2021).
- Truax-Waits, S. D., MSN, CRNA (2017). Considerations of Epidural Analgesia in a Patient with Suspected Uterine Rupture. AANA Journal, 85(2), 136-139.
- Metz, T. D., MD (n.d.). Trial of labor after cesarean birth: Intrapartum management. UpToDate. https://www.uptodate.com/contents/trial-of-labor-after-cesarean-birth-intrapartum-management?search=trial%20of%20labor%20after%20cesarean&source=search_result&selectedTitle=2~42&usag e_type=default&display_rank=2