Name of the Procedure:

Cesarean delivery following trial of labor after cesarean (TOLAC).

Summary

A Cesarean delivery following an attempted vaginal delivery after a previous cesarean delivery (VBAC) is a surgical procedure to deliver a baby through an incision in the mother's abdomen and uterus after an unsuccessful attempt at vaginal birth.

Purpose

The purpose of this procedure is to safely deliver a baby when a vaginal birth attempt has failed after a previous cesarean delivery. This ensures the safety of both the mother and baby due to potential complications that arose during the attempted vaginal delivery.

Indications

• Failure to progress in labor.
• Concerns of uterine rupture.
• Fetal distress or abnormal heart rates.
• Maternal exhaustion or complications.
• Previous cesarean sections with current trial of labor.

Preparation

• Fasting 8 hours before the procedure.
• Adjustments or cessation of certain medications as advised by a healthcare provider.
• Preoperative blood tests, ultrasound, and fetal monitoring.
• Preoperative counseling and consent.

Procedure Description

1. Anesthesia: The patient is given either an epidural, spinal, or general anesthesia for pain management.
2. Incision: A lower abdominal incision (often a horizontal "bikini cut") is made through the skin, fat, and muscle layers down to the uterus.
3. Uterine Incision: An incision is made in the uterus, typically horizontally.
4. Delivery: The baby is gently delivered through the uterine incision. The umbilical cord is clamped and cut.
5. Placenta Removal: The placenta is carefully removed from the uterus.
6. Closure: The uterine incision and abdomen are closed in layers with sutures.

Tools: Scalpel, surgical clamps, sutures, and surgical scissors.

Duration

The procedure typically takes about 45 to 60 minutes.

Setting

Performed in a hospital operating room.

Personnel

• Obstetrician/gynecologist (surgeon).
• Anesthesiologist.
• Surgical nurses.
• Pediatrician or neonatologist (for newborn care).

Risks and Complications

Common risks:

• Infection.
• Blood loss and clotting issues.
• Reactions to anesthesia.

Rare complications:

• Injury to surrounding organs (bladder or bowel).
• Uterine rupture or scar complications.
• Respiratory issues for the baby.

Benefits

• Safe delivery of the baby when vaginal delivery is not possible.
• Prevention of complications associated with failed labor.
• Immediate surgical intervention in case of fetal distress.

Recovery

• Hospital stay of 2-4 days post-procedure.
• Pain management with medications.
• Instructions on wound care and activity restrictions.
• Follow-up appointments to monitor healing.
• Avoid heavy lifting and strenuous activities for about 6 weeks.

Alternatives

• Attempting another trial of labor in future pregnancies (if viable).
• Elective repeat cesarean delivery (eliminating trial of labor).

Pros of alternatives:

• Avoiding surgery with another trial of labor.
• Predictability and planning with an elective cesarean.

Cons of alternatives:

• Repeat trial of labor may also result in emergency cesarean.
• Elective cesarean involves surgical risks similar to emergency surgeries.

Patient Experience

During the procedure, patients under regional anesthesia (epidural/spinal) will be awake but numb from the abdomen down, possibly feeling pressure but no pain. Women under general anesthesia will be unconscious. Postoperatively, patients may experience pain and discomfort at the incision site, which is managed with pain medications. Fatigue and restricted movement are normal, and support with newborn care is often needed. Comfort measures include proper wound care, hydration, and gradual increase in physical activity as recommended by healthcare providers.