VAGINAL BIRTH AFTER PREVIOUS CAESAREAN SECTION ('VBAC')
These guidelines outline agreed regional management for trial for vaginal birth after one previous lower segment Caesarean section (LSCS). Management of individual cases may vary and should be discussed with Consultant.
With a history of one previous delivery by LSCS, the majority of women are suitable for a trial for VBAC in a subsequent pregnancy. The chance of successful vaginal delivery is between 70 - 80%. The incidence of "scar dehiscence" (opening of the scar without serious maternal or fetal consequence) is approximately 0.5% (1 in 200) but the incidence of "scar rupture" (with potential serious fetal or maternal consequences) is lower at 0.1% (1 in 1000)(1). The need for hysterectomy is rare (1). Cautious use of oxytocin augmentation in spontaneous labour is not associated with an increased risk of dehiscence or rupture [OR1.2 (95%CI 0.7-2.1)] (2). However, induced labour, particularly with prostaglandin carries an increased risk of dehiscence or rupture (1,3). These guidelines cover three specific areas:
1. Antenatal management and counselling
2. Induction of labour in cases of VBAC
3. Management of labour for VBAC
Induction of Labour in cases of VBAC
a) Induction of labour should only be undertaken for valid obstetric indications
b) Offer membrane sweep at 41 weeks
c) The preferred method of induction is by forewater amniotomy (ARM) with judicious oxytocin augmentation (as per unit protocol)
d) PG priming should be kept to a mimimum - an experienced obstetrician should assess the need for PG. If PG is necessary, ONE 3mg PG intravaginal tablet only should be used and must be administered on the delivery suite or high dependency area(4). Further doses of PG should only be used after discussion with Consultant.
e) Oxytocin infusion should not be started for 6 hours following PG administration (4). The maximum dose should not exceed 32 mU/min (4).
Management of Labour for VBAC
|Amniotomy (ARM)||- should be considered when the cervix is 3cm dilated|
|IV access||- insert 16G 'Venflon' at the start of labour and take relevant blood tests via cannula before 'Hepsal' and capping|
|Blood tests||- Group & Save (plus Hb if indicated)|
|SpR||- to be informed after initial
assessment by midwife|
|FH monitoring||- continuous electronic FH monitoring throughout labour|
|Progress||- expect normal progress (ie
cervical dilatation of at least |
1cm/hour from 3cm dilatation). If progress is less than this -
experienced obstetrician to review
|Vaginal examination||- 4 hourly up to 7cm dilatation & 2 hourly thereafter: if progress is less than 1 cm/hour, an experienced obsterician must assess and discuss progress with consultant|
|Augmentation||- use agreed unit syntocinon regimen: do not exceed 32mU/min (4)|
|Length||- with epidural, if maternal and fetal condition are good and vertex is not low cavity, allow a maximum of 1 hour for 'passive' descent - consider assistance if spontaneous delivery is not imminent after 1 hour of active pushing (or as otherwise indicated)|
|Forceps/ventouse||- unless the vertex is on or near
the perineum (ie low cavity; |
2-3cm below spines):
a) SpR to examine - and discuss with Consultant before proceeding
b) consider trial of forceps/ventouse in theatre
|Uterine scar||- the integrity of the uterine scar does not
need to be checked |
- D/W consultant if: a) there is persistent or excessive vaginal
bleeding post-delivery or b) if there are concerns about scar
|Length of labour (VBAC)||- inform consultant when
appropriate oxytocin augmentation |
does not correct progress of labour. This review and discussion
should be done earlier rather than later (5).
|Intrauterine pressure (IUP) monitoring||
- routine use of IUP does not improve
obstetric outcome (6) or
|Scar dehiscence & rupture||
Symptoms and signs of impending rupture
- ALL STAFF must be aware of these symptoms &
|Subsequent labours||- the scar rupture rate does not decrease with each subsequent labour: women with a previous LSCS should have ALL subsequent labours managed as described above.|
1. Society of Obstetricians and Gynaecologists of Canada. Vaginal birth after previous Caesarean birth. Clinical Practice Guidelines No 68, December 1997. J Soc Obstet Gynaecol Can 1997; 19: 1425-28.
2. Rosen GM, Dickinson JC, Westhoff CL. Vaginal birth after Cesarean: a meta-analysis of morbidity and mortality. Obstet Gynecol 1991; 77: 465-70.
3. Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior Cesarean section. NEJM 2001; 345(1): 3-8
4. Induction of labour - NICE Inherited Guideline D. National Institute for Clinical Excellence, London, 2001.
5. Turner MJ. Uterine rupture. In: Operative Delivery and intrapartum surgery. Clinical obstetrics & gynaecology - best practice and research. Baskett T, Arulkumaran S (Eds). Bailliere-Tindall, London, 2002. 16(1): 69-79.
6. Chua S, Kurup A, Arulkumaran S, Ratnam SS. Augmentation of labour: does internal tocography result in better obstetric outcome than external tocography? Obstet Gynecol 1990; 76:164-7.
7. Steer PJ, Carter MC, Beard RW. Normal levels of active contraction area in
spontaneous labour. Br J Obstet
Gynaecol 1984; 91:211.
K HINSHAW (on behalf of M&FM Special Interest Group) - May 2003
Please e-mail - email@example.com with any queries
Mr Kim Hinshaw MRCOG
Consultant Obstetrician & Gynaecologist
Sunderland Royal Hospital
Tyne & Wear