What is VBAC

1. DEFINITIONSVBAC (Vaginal Birth After Caesarean) was a vaginal birth process is performed on patients who have had cesarean section in previous pregnancy or have had surgery on the uterine wall (eg one or more intramural myomectomy). This is a vaginal birth after one or more of surgical sesaria.

2. The conduct VBAC REQUIREMENTSAs for some of the requirements that must be met if a patient with a history of SS (cesarean section) to undergo vaginal delivery (Vaginal Birth After Caesarean), namely: a history of cesarean section 1 times with the type of low transverse uterine incision, pelvic area, has never undergone surgical removal of myomas or history torn uterus, doctors assist during childbirth, has the personnel and facilities that can monitor delivery closely, can perform immediate cesarean section in 30 minutes including the readiness of the operating room, anesthesia physicians and other personnel.Some other requirements include:1. There is no indication of cesarean section on pregnancy when the fetus is like latitude, breech, large baby, placenta previa.2. There is a complete medical record of the history of previous cesarean section (the operator, type of incision, complications, duration of treatment).3. Patients soon as possible to being treated in hospital after there are signs of labor.4. Blood available for transfusion.5. Approval of medical follow-on benefits and risks.
Recommendations of the American Obsterticians and Ginecologist (1999) concerning the selection of candidates for vaginal pelahiran with a history of sectio saesarea (VABC)Selection CriteriaHistory of one or two times a low transverse cesarean saesarea.Clinically adequate pelvis.No scarring or other uterine rupture historyDuring active labor is always available doctor who is able to monitor labor and perform an emergency cesarean saesarea.Availability of anesthesia and personnel for emergency cesarean saesareaFrom the american college of obstetricans and ginecologists (1999).From the above table should also be taken into account in the case history of multiple cesarean sectio, scar tissue is not known, buttocks presentation, multiple pregnancy, pregnancy postmatur, and suspicion macrosomia. Prior VBAC held on the above circumstances need to be done further studies about the side effects.Flamm and Geiger score can also be used to assess suitable candidates for vaginal birth. The score Flamm and Geiger for VBAC include:1. Age below 40 years (2 points).2. There is a history of natural childbirth / per vagina:a. Before and after cesarean (4 points)b. After the first fault (2 points)c. Before the first fault (1 point)d. Never had a vaginal birth (0 points)3. Indications of previous cesarean deliveries is in addition to not forward (1poin)Parameters 1-3 this means can be assessed before entering the labor.4. Leveling of the cervix (assessed by the physician in childbirth)
  a. > 75% (2 points)
  b. 25-75% (1 point)
  c. <25% (o points)5. Cervical dilatation at least 4 cm (1 point).Further points add up, and seen the value of the percentage of success:0-2: 42-49%3: 59-60%4: 64-67%5: 77-79%6: 88-89%7: 93%80-10: 95-99%When the percentage of success is less than 50%, patients are strongly encouraged through the fault again. But when more than 90%, recommended through the vagina.

3. The conduct VBAC BENEFITS The benefits of a VBAC compared with cesarean section include:a. Avoiding another scar on the uterus. This is important if you plan on subsequent pregnancies. The more scars that have in the womb, the more likely a problem with the pregnancy later.b. Reducing pain after childbirth so that the hospitalization is shorter.c. Less likely to have difficulty breathing after she was born, although some babies have this problem.d. Breastfeeding is generally easier after a vaginal birth (normal).e. Reduce the risk of infection, injury (bowel, urinary tract, etc.), and the possibility to get blood clots in the legs, which can occur fromoperation.

4. Risks of VBAC.The most serious risk when VBAC is that the C-section scar could open during labor. It is very rare. But when it occurs, can be very serious for both mother and baby. The risk that a scar will tear the very low during VBAC when you have only one low cesarean scar and your labor does not start with medicine. This risk is why VBAC is only offered by hospitals that can perform an emergency C-section fast.Based on several studies that have been done, there are several risk factors for uterine ruptures. Based on the Shipp et al, 2002, maternal age> 30 years 3 times higher risk than women with age <30 years. Spacing of <18 months increased the risk of 3x (Shipp et al 2001), fever after previous cesarean section increased the risk 4x (Shipp et al 2003), stitching 1 layer of the uterus increases the risk almost 4 times compared with 2 layers (Bujold, 2002), number of previous SS> 2x increased risk of 4.5 x (Caughey 1999) while the induction of labor with oxytocin increases the risk of 4.6 x (Zelop 1999). This type is also highly affect its uterine incision. Classical incision / T upside down 4-9% risk of uterine rupture, low vertical 1-7%, while the low transverse incision 0.1 to 1.5%. A history of previous vaginal delivery lowered the risk of rupture 0.2 (Shipp 2000).

5. LABOR MANAGEMENT VBAC.More spontaneous deliveries are expected in women with a history of cesarean section. However, research has been done so far stated that labor induction is safe as long as there are indications in the mother and fetus as well as patients are eligible candidates for VBAC. Drugs that can be used for cervical ripening in the former cesarean section is a prostaglandin E2 gel, a gift can be directly on the posterior vaginal fornix or applied to the cervical canal. Both methods seem fairly safe and effective in patients who will undergo VBAC. Misoprostol is currently very widely used for cervical ripening in women with no history of cesarean section was not be used for the same purpose in the former because of the high incidence of cesarean section scar rupture.Oxytocin infusion is the dominant method for inducing labor or augmentation, and the results of a meta-analysis was incidence of uterine rupture in the former compared with no history of cesarean section cesarean section who received intravenous Oxytocin is balanced, approximately 0.5 -0 1% in both groups.Regarding whether there are differences in doses of Oxytocin in women without and with a history of SC associated with the occurrence of uterine rupture is still a question. Goetzl et al. conduct a case control panelitian about it, and found no significant perbadan in the use of oxytocin among the SC with've never ever, both in terms of the initial dose, dose titration interval, maximum dose, the time when the maximum dose.2.6. IMPLEMENTATION VBACPatients treated at 38 weeks gestation or more and made preparations such as normal delivery. Conducted pemerikssaan NST or CST (if already inpartu), if possible even be continuous electronic fetal heart monitoring. Progress is monitored and evaluated labor as labor is usually, ie using standard partograph. Any pathology or progress of labor, giving an indication for immediate delivery to end it as soon as possible (ie with cesarean section again). Second stage of labor should not be allowed more than 30 minutes, so it must be taken measures to accelerate the second stage (extraction forceps or vacuum extraction) if within that time the unborn baby. It is advisable to conduct exploration / inspection of the integrity of the lining of the uterus after the birth of the placenta, especially at the location of previous cesarean section slices. Expression is strictly prohibited conduct fundus uteri (perasat Kristeller). If the conditions for vaginal delivery not being met (eg, stage II with a head that is still high), cesarean section can be done again. If cesarean section performed again, attempted wherever possible slices follow previous scarring, so that there will be so only one (1) scar / incision.