Today, Heidi Creston gives some nursing insight into the world of obstetrical nursing.
STAT Sections, TOLAC, VBAC, Let’s think about all that . . .
The patient who has had only one prior cesarean section for an indication that no longer presents itself in her next pregnancy may ask the physician for a trial of labor termed trial of labor after cesarean section or TOLAC. For example, if her first baby was breech but the second baby is not. These patients that deliver vaginally are then referred to as successful VBAC (vaginal birth after cesarean section). The patient, however, will undergo a TOLAC for each succeeding pregnancy thereafter.
Midwives, physicians assistants, and nurse practitioners cannot manage the care of these patients alone. There must be a physician present during the labor process. It is important to note that the physician has to agree to the TOLAC. If the doctor does not agree to it then it is the patient’s responsibility to find another physician who will. Some physicians do not carry the insurance for TOLAC or VBAC. There are some states and countries that do not offer TOLAC or VBAC option regardless. Some hospitals do not carry TOLAC or VBAC insurance due to the maternal risks and expenses associated with these procedures. If you’re writing a novel set in a real life state, city, and or hospital with this type of scenario then it would be important to check out these specifics for those locations.
The first thing writers should keep in mind is that cesarean sections are major abdominal surgeries. There is nothing lackadaisical about it. Given that information, any time a muscle in our bodies is cut, torn, or otherwise altered, that muscle is weakened permanently. During a cesarean section the abdominal muscles are both cut and then torn. The uterus is also a muscle. The physician cuts into the uterus in order to remove the baby.
There are two commonly used incisions: Lower Transverse (aka the bikini cut) and the Classical Incision (aka the T-cut). Lower Transverse is the preferred, most common and least damaging of the incisions.
The uterus can develop a uterine window, a fragile site on the uterus that can lead to medical emergencies for the mother and baby. Partial and full abruption of the placenta and ruptured uterus are the most lethal and common complications associated with TOLAC and VBAC procedures.
An abruption is when the placenta dislodges from the uterine wall prior to delivery. In this case, without emergency intervention (imminent birth or emergency cesarean section), the baby will die.
A ruptured uterus is a breakdown of the uterine wall, in which case both mother and baby are at risk for sudden death. Cesarean sections leave the uterus in a compromised state. The more c-sections a patient has, the more compromised the uterus is, which leaves the patient more at risk for abruption and or rupture.
In my experience, patients having had two or more cesarean sections, regardless of the indication, a TOLAC or VBAC are not an option. At this point the risks outweigh the benefits. This risk is so prevalent neither the hospital nor the physicians are willing to accept that responsibility. The physician and hospital will go to great lengths to explain the risk associated with a TOLAC to the patient.
Ultimately the decision is up to the patient. The patient can go against medical advice. Proper paperwork must be filled out indicating that the patient is cognitively aware of their decision and understands the risks involved. The physician and hospital can also file a legal petition to a judge concerning the patient’s decision.
What plot scenario can you think of using these guidelines that will still have a lot of conflict?
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*Originally published 4/25/2011.*