Monday, April 25, 2011

STAT C-sections

I'm so pleased to announce a new guest blogger here at Redwood's Medical Edge. Adelheideh Creston (I call her Heidi) is an RN specializing in obstetrics and neonatology. Her expertise will be an excellent addition to adding medical fact to your fiction. Today, she focuses on what the general guidelines are for vaginal delivery after C-sections. All right men... no blushing.

STAT Sections, TOLAC, VBAC, Let's think about all that.....

STAT C-section definitely gives your story drama, critical hysteria in some cases, just what you need to keep your readers turning pages except....

For the patient who has had only one prior cesarean section for an indication that no longer presents itself in her next pregnancy (for example, if her first baby was breech, but the second baby is not), then the patient may ask the physician for a trial of labor (TOLAC). These patients that delivery 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 patients’ 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.

The first thing to remind everyone 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 a muscle, the physician cuts into the uterus in order to remove the baby.

There are two commonly used incisions: lower transverse (aka bikini cut) and the Classical Incision (aka 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 abruptions 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 a 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?


Adelheideh Creston lives in New York. She is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.
Heidi is an avid reader. She loves Christian fiction mysteries and suspense. Though, don’t recommend the gory graphic stuff to her… please. She enjoys writing her own stories and is yet unpublished. 


  1. Heidi - Great info! I <3 OB/LD nurses! I've had some great ones! [as opposed to my really horrid OB; though I've had a fabulous OB too [and the guy who filled in for her while on maternity leave was great too]].

    Would you be willing to answer a couple of questions for me re LD? Jordyn's given me some great direction, but am still struggling with the nitty gritty...

  2. I'll be glad to help if I can, let me know.