Most women with a prior cesarean delivery and fetal death in the current pregnancy would prefer a vaginal delivery. Although fetal concerns are obviated, available data suggest that maternal risks are increased. Nearly 46,000 women with a prior cesarean delivery in the Network database had a total of209 fetal deaths at an average gestational age of32.8 weeks (Ramirez, 2010). There were 158 women who elected TOLAC, with a VBAC rate of 87 percent. In the entire TOLAC group, the uterine rupture rate was 2.4 percent. Of the 116 women who underwent an induction oflabor, there were five uterine ruptures (3.4 percent).
The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (2017b) recommend delaying nonmedically indicated deliveries until 39 completed weeks of gestation or beyond. As shown in Figure 31-4, signiicant and appreciable adverse neonatal morbidity has been reported with elective delivery before 39 completed weeks (Chiossi, 2013; Clark, 2009). Thus, if ERCD is planned, it is essential that the fetus be mature.
The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) have established the following guidelines for timing an elective cesarean delivery, and accurate gestational dating is suitable using any of these criteria.
1.
Sonographic measurements taken before 20 weeks' gestation support a gestational age :39 weeks.
2.
Fetal heart sounds have been documented for 30 weeks by Doppler ultrasound.
3.
A positive serum or urine �-human chorionic gonadotropin (hCG) test result has been documented for :36 weeks.
Because of uterine rupture risks for women undergoing TOLAC, the American Academy of Pediatricians and the American College of Obstetricians and Gynecologists (2017) recommend that such trials be undertaken only in facilities with staf immediately available to provide emergency care. Moreover, these centers should have a plan and resources for managing uterine rupture. Some argue that these provisions deny women full access to choices. For example, in an earlier survey of Ohio hospitals, 15 percent of Level I, 63 percent of Level II, and 100 percent of Level III institutions met these requirements (Lavin, 2002). Moreover, an obstetrical anesthesia workforce survey reported that due to stafing limitations, TOLAC was allowed in only 88 percent of hospitals with : 1500 annual deliveries, in 59 percent of those with 500 to 1499 deliveries, and in 43 percent of those with < 500 deliveries (Traynor, 2016). In some cases, women choose to attempt TOLAC at a birthing center or at home (Shields, 2017).
Labor induction is associated with a higher failure rate during TOLAC. The risks for uterine rupture, however, are less clear with induction or augmentation, with the exception of prostaglandin E1-misoprostol-which is contraindicated (American College of Obstetricians and Gynecologists, 2017a). Although most institutions are not so conservative, we do not induce or augment labor pharmacologically in women electing TOLAC at Parkland Hospital. Instead, we attempt induction only by amniotomy. Other considerations are to avoid induction or augmentation in women with an unknown prior incision type, an unfavorable cervix, or pregnancy >40 weeks.