TOLAC and VBAC and Rupture! Oh My!

TOLAC AND VBAC AND RUPTURE! OH MY

by, Bree Fallon

As a brand new labor nurse fresh out of school, I distinctly remember visiting with a seasoned traveling nurse, Pam Spivey, during an afternoon of monitoring women on the antepartum unit years ago. One of the preterm women I was caring for that afternoon was planning to attempt a vaginal birth after cesarean (VBAC) with this pregnancy when the time came.  I was pretty green and knew what the acronym stood for, and that was about it. Pam and I began to converse about VBAC and she shared a story of hers from years prior.

She told me about a woman who had been admitted to L&D. The woman had delivered her previous baby in another country by C-section and the plan for her was to allow a trial of labor after cesarean (TOLAC). Pam said her labor progressed beautifully and soon it was time for her to push. I leaned forward on the edge of my seat as Pam recounted the details. She called the provider to come for delivery. “The fetal head crowned up so nicely, and then it was gone!” I felt my eyes grow large. “Where did it go, Pam?!” I thought. She explained the next moments were a mad dash. She pulled all of the cords and plugs out of all of the devices and outlets, grabbed the nursery nurse and down the hall they went with the woman in the bed, snagging the physician on the way as they ran to the OR. Pam even remembered losing her shoe along the way to the OR, but she did not slow down. Confused, I sat in disbelief of this story. Pam recalled the team got the woman to the OR, rapidly delivered her baby via C-section, and both mom and baby survived the ordeal and did well. Still perplexed, I asked out loud this time, “Where did the head go, Pam?” The kind nurse looked at me and explained when a woman’s uterus ruptures, there is no pressure inside the uterus or on the baby anymore. The instant that the head was gone, Pam knew the woman had ruptured her uterus and the lives of both mom and baby were at stake. Horrified, I logged this story away in my brain, vowing to remember what to do when this happened while I cared for a woman.

My first year flew by. Plagued by a horrible cloud of bad luck that followed me on and off of my floor daily, whenever I saw my name assigned next to a woman attempting VBAC, I would swallow the lump in my throat, and Pam’s story would flash in my head. I would mentally prepared myself, ensuring I had my A game for this woman, should any signs or symptoms of uterine rupture arise at any point in the day. The woman would either be successful in delivering vaginally or would not be successful. The only thing that mattered to me at the end of the day was healthy baby, healthy mommy.

A couple years later, my very best friend in the world and an exceptional labor nurse, Kelsey, was pregnant with her first baby. Her baby was breech and was delivered by cesarean. I remember Kelsey laying behind the drape, asking for updates, if her baby girl was ok. Having the privilege of caring for her sweet infant in the OR that day, I swaddled her newborn up as fast as I could. Kelsey had already waited 9 months to meet her daughter, so the extra few moments it took for me to wrap the baby and hand her to Kelsey’s husband before Kelsey could even see her seemed cruel. They snuggled with their new little one while doctor finished the surgery. In the PACU, Kelsey felt pukey and could not hold her infant. Recovery was not easy, but she didn’t know any different. Still today, Kelsey remembers having a difficult time bonding with her infant, and wonders if her delivery by cesarean had anything to do with it.

IMG_6993With Kelsey’s second baby, after discussing the risks and benefits with her provider, Kelsey wanted to attempt VBAC. I was very hopeful for her, but sick to my stomach a little too. Remembering Pam’s story, I was incredible apprehensive and ultimately didn’t want anything bad to happen to Kelsey. Her pregnancy flew by and was induced at 39 weeks and 5 days. I raced to the hospital with the very important job of taking pictures. Kelsey’s labor progressed and she delivered quickly with no complications. Watching my best friend get to see her baby immediately and hold and soothe her right away is one of my most favorite memories of my career. I had taken care of many women who had successful VBAC, but did not really understand its significance until seeing first hand Kelsey and her husband experience both types of delivery.  Never having a cesarean myself, but circulating hundreds, I considered them routine. It was very powerful for me to see the difference between a vaginal birth and a cesarean for the same woman.

Just this week I was asked to review some literature to develop patient education on VBAC. Here are a few facts that stuck out to me taken from ACOG Committee Opinion 342 as well as ACOG VBAC Guidelines.

  • 60-80% of appropriate candidates who attempt VBAC will be successful. The odds are in your favor that a woman will have a vaginal birth.
  • The risks for both elective repeat cesarean and TOLAC include maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. Both have their risks.
  • Overall benefits for a VBAC is avoiding major abdominal surgery. This lowers a woman’s risk of hemorrhage and infection, and shortens postpartum recovery too.
  • The most maternal injury that happens during a TOLAC, happens when a repeat cesarean becomes necessary if the TOLAC fails. Maternal injuries can include uterine rupture, hysterectomy, or even death.
  • There are risks for baby too. Both elective repeat cesarean delivery and TOLAC neonatal complications can include admission to the NICU, hypoxic ischemic encephalopathy, and even death. One study found the composite neonatal morbidity is similar between TOLAC and elective repeat cesarean delivery for women with the greatest probability of achieving VBAC.
  • If a woman has had a prior vaginal birth or goes into labor spontaneously, she has an increased probability of successful VBAC.
  • If a woman had an indication for her initial cesarean that may reoccur with subsequent labors such as labor dystocia or arrest of descent, she has a decreased probability of successful VBAC. If a woman  is of non-white ethnicity, is more than 40 weeks gestation, is obese, has preeclampsia, has a short interval between pregnancy or increased neonatal birth weight, her probability of successful VBAC is also decreased.
  • Women pregnant with twins attempting VBAC have similar outcomes to women with singleton gestations and did not have a greater rate of rupture or perinatal morbidity. (I have never had a twin mom attempt VBAC but it can be done!)
  • On the topic of induction, one study on 20,095 women attempting VBAC found a rate of uterine rupture of 0.52% with spontaneous labor, 0.77% for labor induced without prostaglandins and 2.24% for prostaglandin-induced labor. Prostaglandins should be avoided in the third trimester in women who have had a previous cesarean section.

As years went by, I cared for more women who wanted a vaginal birth after cesarean. I cheered hard for each of them to be able to experience a vaginal birth. Any healthy birth is always a miraculous moment to have the privilege to be a part of. However, caring for women who had only experienced a cesarean before the days of skin-to-skin in the OR and then watching them birth vaginally, and being able to instantly see, touch, hold their infant, is priceless.

In my 12 years of bedside care I worked in facilities delivering on average 4,000- 5,000 babies a year, and a uterine rupture during labor had never happened to one of the women in my care  I was in charge once where one of the nurses correctly identified that the scar on her patient’s uterus was beginning to pull apart. The woman had a cesarean immediately and delivered a healthy baby without any complications. We have had cases of uterine rupture since on my floor. It can happen and if it happens, it becomes an emergent situation that must be resolved swiftly and seamlessly for a good outcome. However, it doesn’t happen very often. In fact, ACOG cites the risk for uterine rupture for woman attempting TOLAC is low, between 0.7-0.9%.

There are many indications where a cesarean delivery is absolutely necessary. In the case of an elective repeat section or a TOLAC, it is imperative that women review the risks and benefits of both with their provider to ensure they make the right choice and promote  a healthy, happy mom and a healthy, happy baby.

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Approaches to Limit Intervention During Labor and Birth

February 2017, the American Congress of Obstetricians and Gynecologists (ACOG) released a committee opinion (Number 687) on limiting intervention during labor and birth. The following is a list of their recommendations:

The American College of Obstetricians and Gynecologists (the College) makes the following recommendations and conclusions:

*For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.
*Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.
*When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.
*Obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term premature rupture of membrane (PROM [also known as prelabor rupture of membranes]) who are considering a period of expectant care of the potential risks associated with expectant management and the limitations of available data. For informed women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for a period of time may be appropriately offered and supported. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.
*Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor.
*For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.
*To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor.
*Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions to best meet the needs of each woman.
*Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.
*When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding outcomes of spontaneous versus Valsalva pushing, each woman should be encouraged to use the technique that she prefers and is most effective for her.
*In the absence of an indication for expeditious delivery, women (particularly those who are nulliparous with epidural analgesia) may be offered a period of rest of 1–2 hours (unless the woman has an urge to bear down sooner) at the onset of the second stage of labor.

The full abstract can be read here.

 

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Chapter Survey

As a new chapter coordinator it can be overwhelming to try and get everything “just right”. Our new Kansas Chapters are a work in progress.  I would like to ask for you all to help us with how you want our bi-monthly meetings to go. We will do our best to incorporate your suggestions into each chapter.

Just a little survey and we may repeat this at a couple of meetings

Chapter Meeting Survey

We appreciate the enthusiasm of our members and community friends, thank you for your time in replying.
jo
Posted in Chapter Meetings, Uncategorized


Are You Registered to Vote?

Image result for get out the vote

Election Day is only 34 days away – are you registered to vote? Whether you live in Kansas or Missouri, your voice matters and will influence how healthcare is shaped in your state! There is still time to register in both states:

Kansas

Missouri

 

 

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RN to BSN

rn2bsn

I graduated with my associates in nursing in 1997. During my program, I don’t really remember a lot of encouragement to go on for my BSN. It was suggested, and a sister school was recommended. I remember thinking that I only needed to do it if I was aspiring to more than basic direct patient care. I wasn’t interested in management and I’m still not. I had considered certified nurse midwife for a while, but it felt like a pipe dream because my life was too busy, or so I thought. As the years went by, I was content to just keep doing what I was doing and my ADN was fine for that. More years went by; 18 to be exact. It became something that was terrifying to me because it had been so long since I’d been a student. There was no way I’d be able to do that again. But then something happened. I was asked to be a preceptor at work. I really liked it. Then, I started being asked to take students on clinical. I REALLY liked that. I slowly began to see that I had a gift for teaching and I also happened to love doing it. So I began the arduous process of researching the best way for me to become a nurse educator. It took me about six months to settle on a learning path and location. I knew it needed to be all online because my work schedule would not allow me to attend regular lectures. I also needed a school that wasn’t going to require that I retake any classes because they’d outdated. After all, some of my classes, like Algebra, were 25 years old and I sure didn’t want to take that again! I also needed something that would not completely break my bank. Fort Hays State University met all of my requirements.

I started classes in the summer term of 2015. I took 7 hours that summer, 12 hours each of the next three regular semesters, a 3 hour intersession course, and 5 hours the following summer. I am currently taking my last 9 hours and plan to graduate with my BSN in December. All total, it will have taken me 18 months to complete my BSN. I had several prerequisites I was missing that many other people probably wouldn’t have to take. It adds up to a total of 15 hours of non-nursing courses plus statistics and pathophysiology that may have been obtained in an associates program other than mine. This means that a person could complete the program in 12 months.

I admit, I went into this thinking that getting my BSN was simply a necessary stepping stone to obtaining my MSN. I’d been a nurse for 18 years and I believe I’m a very good nurse. What could I possibly learn? Boy was I surprised! Yes, I was annoyed at the class that focused on why obtaining a BSN was so important. I seemed to heavily push the idea that ADNs were not good enough. That can be very hurtful to someone who has been a very effective RN with an ADN. I still believe that the approach in this class could be softened a bit, but I eventually came to understand the rational behind the message. I do believe I am a better nurse for having gone through these classes. I am more critical of research I read with the back ground knowledge telling me how to judge the quality of the research. I have a deeper understanding of what it is to be a nurse leader and why it falls to each of us as RNs to step up and be leaders. I learned a lot about legal aspects of nursing and how actions I thought would protect me from a lawsuit aren’t actually protection at all. I also came to understand how important it is to be involved in nursing legislation. Finally, I gained an understanding of the importance of professional organization membership. My practice has changed some during my time of pursuing my BSN. What has been completely made over is my understanding of my role in nursing, both for my patients and my colleagues. I realize now that having a BSN should be foundational for all of nursing practice, even if one has no goals of obtaining an advanced degree.

Here’s a link to get you started in looking at schools in Kansas that offer an RN to BSN program. If you’ve been considering it, do it! You will not regret it!

staceyrnsig

 

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September Chapter Meetings

From Jonnie:

The AWHONN KC Metro Chapter meeting for September was a hit. We had 22 participants attend the meeting held at The University of Kansas Hospital. After the webinar New Research and Strategies to Support and Promote Breastfeeding we had a panel of Lactation Consultants from different hospitals sharing their experiences with the Baby Friendly process. We raised $15 for the diaper drive with raffle and give aways from AWHONN and the National Convention. It was great to Network with nurses from at least six different entities. We hope to keep growing our numbers at the next meeting scheduled for November 29th at Overland Park.

 

From Stacey:

The South Central Kansas Chapter meeting was an intimate affair with three members attending. We met at Newman University in a beautiful location that is warm and inviting. We viewed the webinar, New Research and Strategies to Support and Promote Breastfeeding, and discussed breast feeding support in each of our respective areas. One member currently works at a Baby Friendly certified facility and both of the other two members are in varying stages of Baby Friendly certification. It’s great to see hospitals recognize the importance of supporting breast feeding women and putting the work into showing that support with Baby Friendly certification! Our next meeting is scheduled for November 28th.

 

Virtual attendance update:

We expect to have the technology in place for at least one, if not both of the November meetings to be streamed live so you can participate even if yo are unable to attend in person.

 

Posted in Chapter Meetings


Welcome to AWHONN Kansas!

Over the past several years, work has occurred to re-engage our AWHONN members in Kansas. We have a strong history of commitment to our professional nursing organization in Kansas from the early days of NAACOG to our current AWHONN organization.

We are poised to provide some “value-add” to our 235 AWHONN members across the state. Check out the leadership summary to learn more about the folks, with your same passion, who have stepped forward to lead our state. I am thrilled to have these professional nurses on board to assist with implementing in Kansas the AWHONN mission of improving and promoting the health of women and newborns as well as strengthen the nursing profession.

The American Nursing Association (ANA) describes the standards of professional nursing practice by articulating standards of practice (the nursing process) and professional performance.  Professional performance includes concepts like education, evidence-based practice and research, leadership and collaboration to name a few.

Providing a way to reach out and learn from each other is one way to strengthen our nursing professional performance.   A blog is a simple way to seek out information or ideas, share knowledge and discuss challenges.

I hope you enjoy AWHONN Kansas blog and find it as one new feature to add value to your membership and strengthen your professional nursing practice.

~Lisa Alexander

KS AWHONN Section Chair

ANA Scope and Standards of practice

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