April’s entry in the Maternal Fetal Medicine Case Series outlines an unusual and yet well-defined risk of a uterine rupture. The article, ‘An Intrapartum Emergency: Neonatal Implications,’ details a case of a uterine rupture in an obstetrical patient undergoing a trial of labor after cesarean (TOLAC). A uterine rupture, similar to the highlighted article, is an obstetrical emergency, during which minutes matter, and there is real potential for maternal and fetal morbidity and even neonatal mortality. Albeit unlikely, these risks can include neonatal morbidity resulting from hypoxic ischemic encephalopathy and even neonatal mortality. A pediatrician called to the resuscitation of a neonate following a similar emergent cesarean delivery as outlined in the April Maternal Fetal Medicine Case Series may appropriately think to themselves: “why not just a scheduled repeat cesarean?”
The question is a good one. During their antenatal counseling of pregnant individuals who are considering a TOLAC, obstetrical providers counsel about the unlikely, but very real, risk of uterine rupture and the unlikely maternal and neonatal risks. The majority of patients (60-80%) undergoing trial of labor will be successful and the likelihood of uterine rupture with one prior low transverse cesarean scar is 0.5-0.8%.1 Benefits of a successful vaginal birth after cesarean (VBAC) include many health advantages for the parent and their neonate. These benefits include higher rates of breastfeeding, lower rates of maternal thromboembolism, blood loss, rates of infection, and a shorter maternal recovery.1,2
For parents who plan on further expansion of their family, future benefits of a successful VBAC may lead to a > 90% likelihood3 of recurrent successful vaginal delivery and reduced likelihood of placenta accreta spectrum. Higher-order repeat cesareans and subsequent accreta is a leading cause of maternal transfusion, maternal morbidity, and blood loss anemia.4For our would-be pediatrician asking about repeat cesareans, determining the approach of a trial of labor after cesarean versus scheduled repeat cesarean appropriately necessitates a conversation between the maternal patient and their obstetric provider using a shared decision-making model, where the patient’s autonomy is respected, and there is clear review of the associated benefits and risks. I hope that April’s Maternal-Fetal Medicine Case sheds some light on this issue and helps facilitate better communication with parents.
References:
- Vaginal birth after cesarean delivery. ACOG Practice Bulletin No 205. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2019;133:e110-27
- The Influence of mode of delivery on breastfeeding initiation in women with a prior cesarean delivery: a population-based study. Breastfeed Med. 2013;8(2):181-186
- https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator Version 2.0. Accessed 2.12.2023
- Robert M Silver,Mark B Landon, Dwight J Rouse, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006;107(6):1226-32
