Cesarean and vbac study Group Module Learning Objectives



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Cesarean and VBAC

Study Group Module


Learning Objectives

Review the following Learning Objectives as an organized beginning to your study of this module. As you read the Learning Objectives, note key words which will aid you in finding the information in the texts. When you complete the module, revisit this list and check for areas that require further investigation.




  • Identify the national statistics on cesarean section.

  • Identify the cesarean rate prior to 1970, and the causes for its increase.

  • Identify the surgical procedure of cesarean section.

  • Understand how to advocate for your client in a transport situation.

  • Review CPD and “failure to progress.”

  • Review fetal heart rate patterns and fetal distress.

  • Make a transport plan for addressing cord prolapse.

  • Understand the anger and emotional healing women may experience after a cesarean section.

  • Identify the importance of continuity of midwifery care in a complicated birth experience.

  • Define VBAC and YBAC.

  • Identify the risks and benefits of vaginal birth after cesarean section.

  • Identify the importance of reviewing the previous OB cesarean records.

  • Define scar dehiscence.

  • Identify the incidence and symptoms of uterine rupture.

  • Identify instances when cesarean sections are indicated.

  • Identify the recommendations made by WHO regarding cesarean rates.

  • Identify the recommendations made by ACOG regarding VBAC.

  • Identify local community standards regarding VBAC.

  • Determine your own practice guidelines for VBAC/YBAC.

  • Review Pharmacology for Midwives regarding epidural, IV, and pain relief.

  • Identify specific post partum care and support for women recovering from cesarean section.

  • Identify national and community resources for VBAC support.


Study Sources

The following texts are recommended for completion of this module. Use them to cross reference and build a more comprehensive understanding.

Using key words from the Learning Objectives, search the index. Read those pages listed, and read the chapter in which they are found. Establish a context for the information so that you understand how other topics are related. In addition, read the chapter headings in the Table of Contents, and flip through each text to familiarize yourself with the content of chapters. As you work through Study Group modules, you will eventually read each text in its entirety.


  • History of Cesarean” article for ACOG in cooperation with the National Library of Medicine.

  • example operative report

  • Study Finds Induction Increases Risks for VBACs

  • Documents in defense of VBAC

  • Human Labor and Birth, Oxorne and Foote

  • Varney’s Midwifery

  • Myles Textbook for Midwives

  • Holistic Midwifery, Vol. I, II, III (when available), Frye


Related Topics

  • CPD and “failure to progress.”

  • Fetal Heart Rate Patterns

  • Grief

  • Breastfeeding

  • Post partum depression

  • Second stage

  • Breech

  • Twins

  • Asphyxia

  • Herpes

  • Postpartum care

  • Female sexuality

  • Transporting

  • Charting

  • Informed Consent

  • Pharmacology for Midwives


Cesarean Section Operative Report
Preoperative Diagnosis:

1. 23 year old G1P0, estimated gestational age = 40 weeks

2. Dystocia

3. Non-reassuring fetal tracing

Postoperative Diagnosis: Same as above

Title of Operation: Primary low segment transverse cesarean section

Surgeon:

Assistant:

Anesthesia: Epidural

Findings At Surgery: Male infant in occiput posterior presentation. Thin meconium with none below the cords, pediatrics present at delivery, APGAR's 6/8, weight 3980 g. Normal uterus, tubes, and ovaries.

Description of Operative Procedure:

After assuring informed consent, the patient was taken to the operating room and spinal anesthesia was initiated. The patient was placed in the dorsal, supine position with left lateral tilt. The abdomen was prepped and draped in sterile fashion.

A Pfannenstiel skin incision was made with a scalpel and carried through to the level of the fascia. The fascial incision was extended bilaterally with Mayo scissors. The fascial incision was then grasped with the Kocher clamps, elevated, and sharply and bluntly dissected superiorly and inferiorly from the rectus muscles.

The rectus muscles were then separated in the midline, and the peritoneum was tented up, and entered sharply with Metzenbaum scissors. The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder.

A bladder blade was then inserted, and the vesicouterine peritoneum was identified, grasped with the pick-ups, and entered sharply with the Metzenbaum scissors. This incision was then extended laterally, and a bladder flap was created. The bladder was retracted using the bladder blade. The lower uterine segment was incised in a transverse fashion with the scalpel, then extended bilaterally with bandage scissors. The bladder blade was removed, and the infants head was delivered atraumatically. The nose and mouth were suctioned and the cord clamped and cut. The infant was handed off to the pediatrician. Cord gases and cord blood were sent.

The placenta was then removed manually, and the uterus was exteriorized, and cleared of all clots and debris. The uterine incision was repaired with 1-O chromic in a running locking fashion. A second layer of 1-O chromic was used to obtain excellent hemostasis. The bladder flap was repaired with a 3-O Vicryl in a running fashion. The cul-de-sac was cleared of clots and the uterus was returned to the abdomen. The peritoneum was closed with 3-0 Vicryl. The fascia was reapproximated with O Vicryl in a running fashion. The skin was closed with staples.

The patient tolerated the procedure well. Needle and sponge counts were correct times two. Two grams of Ancef was given at cord clamp, and a sterile dressing was placed over the incision.

Estimated Blood Loss (EBL): 800 cc; no blood replaced (normal blood loss is 500-1000 cc).

Specimens: Placenta, cord pH, cord blood specimens.

Drains: Foley to gravity.

Fluids: Input - 2000 cc LR; Output - 300 cc clear urine.

Complications: None.

Disposition: The patient was taken to the recovery room then postpartum ward in stable condition.

 

Study Finds Induction Increases Risks for VBACs



Mona Lydon-Rochelle, Holt, Victoria L., Easterling, Thomas R., Martin, Diane P. “Risk of Uterine Rupture during Labor among Women with a Prior Cesarean Delivery” New England Journal of Medicine, Vl 345, No. 1, July 5, 2001.

A new study that looks at the risk of uterine rupture during labor for VBACs (vaginal birth after cesarean-section) was picked up by newspapers across the country, but many headlines announced that VBACs are dangerous, a gross distortion of the study’s findings. National organizations including the ACNM and the International Cesarean Awareness Network issued press releases, and through the Grassroots Network CfM urged people to respond with letters to the editor of their local newspapers.

The most important finding was that for hospital VBACs (after one c-section) induction of labor significantly increases the risk of uterine rupture, and the use of prostoglandins greatly increases the risk of rupture (15 times higher than those who had second cesaraeans). In other words, the real problem is the first c-section (which accounts for 2/3 of the US c-section rate of 22% in 1999), with the risks greatly increased when labor is induced especially with prostaglandins.

Data for women who had a first (single) baby by c-section from 1987-1996, and subsequently gave birth to a second live single infant during the same period of time (20,095 women, based on Washington State records for hospital births), were analyzed in this study. The study found:

Rate of uterine rupture in second birth for women with one prior c-section (per 1000)

Repeat c-section without labor 1.6 (11 of 6,980 women)

Spontaneous onset of labor 5.2 (56 of 10,789 women)

Labor induced without prostaglandins 7.7 (15 of 1,960 women)

Labor induced with prostaglandins 24.5 (9 of 366 women)

The study did not address many significant issues. For example, uterine rupture can include anything from relatively minor separations at the scar site, to sudden and catastrophic multiple large tears of the uterus. However, accuracy of reported uterine rupture was barely touched upon, and degrees of severity were not discussed. Because the study focused only on the risk of uterine rupture, the risks associated with the cesarean delivery procedure itself were not discussed, even though these would be very relevant for informed decision-making. There was no mention of other interventions that could possibly affect outcomes, such as augmentation of labor (can cause abnormally strong contractions) or the use of epidurals during labor (can mask early symptoms of uterine rupture). The authors did acknowledge that they lacked information regarding specific types and dosages of prostaglandins used, although the controversial use of Cytotec was not known to be used prior to the last year of the study. Finally, there was no discussion or information regarding the timing (number of weeks of gestation) or reasons for induction.

The study included only hospital births, and did not distinguish between natural childbirth (no interventions) and standard hospital-managed birth.

The study actually confirms what the midwifery community has been saying for years: outcomes for VBACS that are allowed to labor normally, without induction or augmentation, are good. And women who have had a previous c-section are definitely not candidates for labor inducing drugs, which exert added stress to a uterine wall that is already weakened or at least changed by the scar tissue.

Women who are making decisions about attempting a VBAC should understand the results of this study (and its limitations). In addition, this information is essential for any woman who is “offered” an elective c-section, or whose caregiver recommends a c-section, so she can be aware that a c-section today significantly increases risks associated with any future pregnancy. Of course, she should also have full information on the relative risks of any c-section for herself and her baby.

As ICAN states in their press release (see below), “…the risk of uterine rupture [for a VBAC] remains low when labor is allowed to start on its own.”


Related articles of interest

Trial of Labor After 40 Weeks’ Gestation in Women With Prior Cesarean Carolyn M. Zelop, Thomas D. Shipp, Amy Cohen, John T. Repke, & Ellice Lieberman Obstet Gynecol 2001;97(3):391?393. The authors concluded, “Because spontaneous labor after 40 weeks is associated with a cesarean rate similar to that following induced labor before 40 weeks, awaiting spontaneous labor after 40 weeks does not decrease the likelihood of successful vaginal delivery.”

· Press Release: “International Cesarean Awareness Network Affirms Safety of Vaginal Birth After Cesarean”

From the ICAN Press Release: http://www.ican-online.org/info/news/070601.htm

“… In fact, the risk of rupture for women who begin labor spontaneously was shown to

“Standing up to the VBAC-lash: A critique of the New England Journal of Medicine VBAC study and implications for the future of the medical model of childbirth.” by Jill MacCorkle. Published on the internet at www.maccorkl.home.sprynet.com/VBAClash.htm: This is a thorough and well-referenced paper that also includes information regarding the risks associated with c-sections in general and the evidence supporting the benefits of VBACs.

· For a discussion issues associated with reporting of uterine rupture, read “Use of Hospital Discharge Data to Monitor Uterine Rupture – Massachusetts, 1990-1997” Morbidity and Mortality Weekly Report (March 31, 2000 / 49(12);245-8) which can be found at: www.cdc.gov/mmwr/preview/mmwrhtml/mm4912a1.htm
CfM Response To NEJM VBAC Article
Dear Editor,

Birth is the leading reason for hospital admission in this country. Cesarean delivery is the most common surgery performed in the United States. The most common cause of death in postpartum women is complications from cesarean delivery.

In the face of these facts, it is shameful that the media response to the New England Journal of Medicine study (July 5, 2001) has been to focus on the risks of vaginal birth, and not the risks of routine medical interventions, such as prostaglandin induction and elective repeat cesarean.

The study points to a 0.5% risk of rupture among post-cesarean women who labor without induction. Other studies have produced similar numbers that were used to support the practice of VBAC. Why? Because even with this risk, the mother is still twice as likely to die from complications of elective repeat cesarean birth compared to vaginal birth.

Every maternity care provider has an ethical obligation to honestly describe both options to the mother as part of her informed decision-making process. Apparently there is no such obligation in the public dialogue of this issue – there is no patient, only a large and suggestible audience.

Sincerely,

Susan Hodges, President, Citizens for Midwifery

Willa Powell, Board Member, Citizens for Midwifery

Citizens for Midwifery is the only national consumer organization advocating the Midwives Model of Care

September 2001


October 3, 2001
Dear Members of the Legislative Committee on Administrative Rules:
I am writing on behalf of the Vermont Midwives Alliance in response to the committee hearing on the Midwifery licensing rules held on Wednesday, September 19, 2001. First, we would like to commend the work of the Advisory Committee and all the legislators who have taken part in the formation of the Midwifery legislation. Enclosed you will find two pertinent reports, one from the Pew Health Professions Committee and one from the American Public Health Association, which specifically support the licensing of midwives.

The main purpose of this letter is to address the issue of VBAC at home, which was by far the most controversial aspect of the hearing. It was disappointing to those of us who support the rules and regulations as presented that the opposition had so much more opportunity to testify than we did. We believe the committee members were left with a rather unbalanced picture of this issue.


The question of civil liberties

The first important question is how much freedom do we legislate away in an effort to reduce risk. If we use Dr. Capeless's figures (which came from The New England Journal of Medicine article of July 5, 2001), specifically that the rupture rate is somewhere between 1 in 250 and 1 in 400, and that 25% of those will have a poor outcome, then the conservative figure of risk is 1 in 1000 of having a poor outcome. We ask you if you feel it is appropriate to limit personal choice and freedom when the person has a 99.9% chance of having a good outcome. Even if the figure was only 99%, legislating against personal freedom makes the assumption that women and their families are incapable of making sound choices for themselves. One of the stipulations in the rules as they were presented requires the midwife to have signed informed choice for any woman having a VBAC at home, so the committee can be assured that the family is making this decision with full knowledge of the risk involved. The reality is that most women will not choose to have a VBAC at home. But for the few that do, their conviction about their decisions is very strong. They make an informed choice, fully aware of the risks and the benefits to themselves and their baby in choosing a home birth.

After Dr. Capeless's description of the worse case scenario, many of you were asking yourselves why would anyone choose a home VBAC? Rep. Dakin even said, "I don't know why any woman would take any risk." The fact is that all the technology in the world cannot eliminate all risk from birth. No well-designed study has ever shown hospital birth to be safer than home birth for a low risk woman. Women choose midwifery care and home births for

a variety of reasons. But all of them come to the conclusion that it is the best choice for them. Universally they receive more time and attention, more preventive services such as extensive nutritional counseling, continuity of care, and one-on-one, continuous labor support.


Is Home VBAC the biggest issue?

It is interesting that so much time, energy and attention has been paid to this issue by various physicians and their lobbyists. We are literally talking about 5 or 6 women each year, who choose home VBAC (Vermont birth certificate statistics quote 61 home VBACs in the past 11 years). There are 6000-6500 hospital births in Vermont each year and most hospital cesarean rates are between 18-23%. Physicians might be asking some different questions about what best serves Vermont women. Most home birth midwifery practices have cesarean rates of 2-4%. Clearly some part of this excellent figure is due to self-selection, but by no means all of it. The World Health Organization suggests that cesarean rates over 7% are in excess of what actually improves outcome for babies and are therefore unwarranted. That means that almost two out of every three cesareans performed in this country are unnecessary. Cesareans are known to be more dangerous to mothers, with infection and hemorrhage levels much higher than vaginal delivery and with the mortality rate at 3-4 times that of vaginal birth. The next time the woman becomes pregnant she faces a higher rate of uterine rupture, no matter whether she chooses repeat section (uterine ruptures do occur before the onset of labor), hospital VBAC, or home VBAC. Clearly unnecessary cesareans present a far greater risk to far greater numbers of Vermont women than home VBACs.

In light of these statistics and other areas of disparate outcome, such as prematurity rates, we question the implication at the hearing that midwives expose women and babies to unnecessary risks, while doctors advocate for their safety. Of course no one wants to experience a uterine rupture, either at home or in the hospital. However, all of us face risk taking decisions every day (driving around in our cars, for instance), and we all do not balance risks and benefits in the same way; that is part of our right to self-determination in a democracy.

Implications of new research for home VBAC

The physicians who testified against VBAC at home talked about new research that questions the more established assumptions about VBAC safety. What was not delineated was that the likely explanation for this difference is changes in obstetrical management. It is not women's bodies that have changed, but what is done to them during childbirth. In some of the studies we see one factor that quite definitely increase uterine rupture rate is the off-label use of cytotec for induction of labor. Other types of prostaglandin induction agents have also been shown to increase risk. The use of Pitocin for both induction and augmentation is questionable. These are not practices used in home birth. And lastly there is the newer surgical closure method in which a single layer of sutures is used rather than a double layer. This method was instituted and taken up by many obstetricians across the country before its safety was verified. Once again we must ask, who really is exposing women and their babies to increased risk? In the rules as presented, midwives are not allowed to attend women with single layer closures of a previous cesarean in the home.
Paradigm differences and evidence based practice

We believe that the physicians who testified were motivated by what they consider to be the best interests of women and babies. However, we also believe that they operate from a distinct paradigm that opposes home birth on principle, despite lack of evidence that it is an unhealthy choice. They are not sensitive or even aware of the many factors affecting women's choices in birth. (This is not true of all physicians, of course, and there are physicians who support and understand home birth including those who choose it for themselves.) I have heard various physicians say they felt women choosing a home birth were selfish because they were only concerned about their own experience. This can not be farther from the truth. Many women choose home birth specifically because they believe it will be a much healthier experience for their baby. They believe hospital interventions both before and after the birth have their own risks. As a midwife I find this presumption of selfishness to lack respect for the deep wisdom that what is good for the mother is also good for the baby. Stress hormones affect blood flow and they affect the progress of labor. If a woman is anxious, afraid, and unsupported during labor she is more at risk for problems. This has been eloquently demonstrated by the "doula" studies.

Two separate studies were performed on very large numbers of women in Guatemala and Texas. Matched groups of women having babies in big city hospitals were streamed into a group that labored with conventional hospital services and one which had the addition of an untrained "doula" or labor support woman who stayed at the laboring woman's side throughout labor (often simply just holding the woman's hand). Outcome differences were

impressive: shorter labors, fewer cesareans, fewer babies in the intensive care nursery, were but a sample of the improved outcomes for women with doulas. As a midwife I never encourage a woman to choose home birth in the initial interview. I always tell her she needs to determine where she will feel most safe and secure, because that is where her labor will proceed most smoothly and safely.

We understand that there is intense political pressure on the members of the committee to vote against the VBAC inclusion. Physicians have a lot of power in both money and connections. But we hope that you will think of your charge to represent the citizens of Vermont when you make this decision. We honestly wish all of you could have attended the public hearing on the rules and regulations. Several dozen mothers spoke eloquently and passionately of their experiences of home birth and midwifery care. All of them advocated for the passing of the rules as presented, and a number of them asked for an addition of a waiver that would allow any woman to be attended at home with informed choice. It is important to remember that some women are so dedicated to having their baby at home that they will labor unattended, if they cannot find a midwife. This certainly has potential to increase risk, and it is not in the interest of public health to disallow such women care. Vermont is a very special place for a number of reasons.

One of these reasons is that citizens have a real voice in government and special interest groups are somewhat less powerful than they are elsewhere. We hope you will listen to the voices of citizens, the people directly affected by these rules and regulations. Please ask yourselves if you can justify limiting the civil liberties of a handful of families when they have a 99-99.9% chance of having a good outcome.

Please vote to preserve the freedom of Vermonters.
Sincerely,

Laurie Foster, CPM, CNM, MS



On behalf of the Vermont Midwives Alliance

Cesarean and VBAC Questions

  1. What are the national cesarean statistics?



  1. What was the cesarean rate prior to 1970?



  1. What single major medical intervention accounts for much of this increase?



  1. What additional factors have contributed to increasing the cesarean rate in the U.S.?



  1. What does the World Health Organization estimate the rate of necessary cesarean to be? (This is the WHO challenge to global obstetrics.)



  1. How does the classical cesarean differ from the low transverse cesarean as a surgical procedure, and how does the incision relate to safety of VBAC?



  1. How does “single layer closure” differ from “double layer closure” in terms of surgical history and safety of VBAC?



  1. What is a VBAC?



  1. What is a YBAC?



  1. What questions are critical to helping a woman make her decision about where to have her baby by VBAC?



  1. What does a diagnosis of CPD in a previous birth apply to subsequent births?



  1. What does ‘failure to progress’ mean?



  1. What is most important to achieve when advocating for your client in a hospital transport situation?



  1. How do hospital policies regarding an emergency cesarean differ from a non-emergency cesarean?



  1. Cesarean section is major abdominal surgery. List the physical effects that a woman recovering from a c-section is likely to experience. Begin with her immediate post partum and continue through 6 weeks.



  1. What are the usual medical treatments in the 48 hours following a cesarean?



  1. As a midwife, what can you do to help a woman after a cesarean section?



  1. Which homeopathic remedies are indicated for someone recovering from a cesarean?



  1. What are the the risks and benefits of vaginal birth after cesarean section?



  1. What is scar dehiscence?



  1. What are the symptoms of uterine rupture?



  1. What is the incidence of uterine rupture for VBAC and non-VBAC?



  1. In what instances are cesarean sections indicated?



  1. When are mothers reunited with their babies after cesarean?



  1. What is the treatment for an abdominal cesarean incision that is not healing well?



  1. What are the ACOG recommendations for VBAC?



  1. What is the availability of anesthesia in the local hospitals that receive midwife transports? Why is it important to know this and how does it impact your decision making as a midwife?



Essay

  1. Describe the surgical procedure for a low transverse incision cesarean section.



  1. Give detailed instructions for managing a cord prolapse, including transport.



  1. What are some possible emotional responses a client may have following a cesarean section?



  1. What is the local community standard for VBAC?



Projects

(send completed projects with the rest of your course work for this module)




  1. Draft practice guidelines for VBACs in your own practice. Include reference to your transport plan in response to need for labor augmentation, maternal exhaustion, fetal distress. Submit this draft and include it later in your Practice Guidelines projects (in the Charting and Practice Guidelines Module.)



  1. If your practice guidelines include attending home VBACs, create an VBAC informed choice/informed consent document for your charts.



  1. Draft practice guidelines for clients who require cesarean sections in your own practice. Include reference to your transport plan in response to need for labor augmentation, maternal exhaustion, fetal distress, advocacy in the hospital and specific immediate post partum care for mother and baby. Submit this draft and include it later in your Practice Guidelines projects (in the Charting and Practice Guidelines Module.)cord prolapse,



  1. Create a post partum care plan for women recovering from cesarean section. Include details of care.



  1. Create a list of local resources for women recovering from cesarean, and for women choosing VBAC. Include local contacts for regional or national organizations, as well as online resources.



  1. Choose a book about cesareans to recommend to your clients. Write a review about your recommendation, include title, author, publisher and date of publication.



Skills

Following are excerpts from the NMI forms for assessment of midwifery skills, which include all skills identified and required by NARM. Review the following skills and consider how they each relate to the content of this module. If you are currently working with a preceptor, take this opportunity to focus on these areas. During Supervised Primary Care you will formally evaluate these skills together using the NMI form Preceptor Evaluation/Student Self-Assessment of Midwifery Skills.


1. Midwifery Counseling, Education and Communication:

A. Provides interactive support and counseling and/or referral services to the mother regarding her relationships with her significant others and other health care providers B. Provides education, support, counseling and/or referral for the possibility of less-than- optimal pregnancy outcomes

C. Provides education and counseling based on maternal health/reproductive/family history and on-going risk assessment

D. Facilitates the mother's decision of where to give birth

1. The advantages and the risks of different birth sites

2. The requirements of the birth site

3. How to prepare, equip and supply birth site

E. Educates the mother and her family/support unit to share responsibility for optimal pregnancy outcome

F. Educates the mother concerning the natural physical and emotional processes of pregnancy, labor, birth and post partum

G. Applies the principles of informed consent

H. Provides individualized care

I. Advocates for the mother during pregnancy, birth and postpartum

J. Provides education, counseling and/or referral, where appropriate for:

7. Sexually transmitted diseases

8. Complications

11. Postpartum care concerning complications and self-care

3. Maternal Health Assessment:

G. Evaluates laboratory and medical records from other practitioners



H. Obtains assistance evaluating laboratory and medical records from other practitioners
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