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Vaginal Birth After Cesarean
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7. Risk Scoring and Management systems
If one has the following factors, then how should clinically manage to maximize the benefit for the patient?
TOLAC Risk factors
Northern New England Perinatal Quality Improvement Network
Low Risk Patient:
- 1 prior low transverse cesarean delivery
- Spontaneous onset labor
- No need for augmentation
- No repetitive FHR abnormalities
- Patients with a prior successful VBAC are especially low risk.
(However, their risk status escalates the same as other low risk patients)
Medium Risk Patient:
- Induction of labor
- Pitocin augmentation
- 2 or more prior low transverse cesarean deliveries*
- < 18 months between prior cesarean delivery and current delivery
High Risk Patient:
- Repetitive non-reassuring FHR abnormalities not responsive to clinical intervention. /li>
- Bleeding suggestive of abruption
- 2 hours without cervical change in the active phase despite adequate labor
* NB: 'Two prior uterine scars and no vaginal deliveries' is listed as a circumstance under which trial of labor should not be attempted by the American College of Obstetricians and Gynecologists ACOG Practice Bulletin No. 54, 'Vaginal birth after previous cesarean delivery'.
Here is one suggested management system
Management system
Northern New England Perinatal Quality Improvement Network
Low risk
Notify Pediatrics, Anesthesia, and operating room crew of admission
OB/GYN on campus during active phase
Perinatal Guidelines of Care, ACOG, observed
Medium risk
Notify Pediatrics, Anesthesia, and operating room crew of admission
Operating room on campus in active phase or other plan if crew is busy
High risk
OB/GYN, Anesthesia, and Pediatrics available
No other acute care responsibilities
Rapid decision to incision
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