Beruflich Dokumente
Kultur Dokumente
Change History
Version Date Author, job title Reason
3.0 April 2014 Emma Maycock, Midwife Review of existing guideline to
reflect change of practice
3.1 November P Street (Consultant Pg 7 – Augmentation
2014 Obstetrician)
3.2 April 2015 C Harding (Clinical Lead Update of the auditable
Midwife D/S) standards on page 8
Updated VBAC counselling
checklist pg 11/12
4.0 Oct 2015 Jane Siddall (Consultant Reviewed against updated
Obstetrician) RCOG green top No 45
published 1/10/15
4.1 Mar 2017 C Harding (Consultant MW) App 2 – VBAC pathway updated
5.0 Oct 2017 J Bussey (VBAC specialist Reviewed – App 1 VBAC
MW) counselling checklist updated
C Harding (Consultant MW), P Pg 2, 3, 5 & 7 changes made to
Bose (Consultant reflect current practice.
Obstetrician),
Aim: To present the best available evidence to facilitate antenatal counselling in women
with one prior CS birth and to formulate intrapartum management.
Introduction
Increasing rates of primary caesarean section have increased the population with a history
of prior caesarean delivery. Women with previous CS may be offered either planned
Vaginal Birth after Caesarean Section (VBAC) or elective repeat caesarean section
(ERCS)
Although there are no randomised controlled trials comparing planned VBAC with planned
ERCS, VBAC remains a safe option and should be recommended to women with a prior
history of one uncomplicated lower segment transverse caesarean section in an otherwise
uncomplicated pregnancy at term¹.
Antenatal counselling
Women with a prior history of one uncomplicated lower-segment transverse CS, in
an otherwise uncomplicated pregnancy at term, with no contraindications to vaginal
birth, should be referred to the midwife-led VBAC clinic to discuss the option of
planned VBAC.
All of these women should be provided with a VBAC patient information leaflet at
her booking appointment with the community midwife. If the mother has not
received one, a copy should be given to her at the hospital appointment.
There should be a review of the operative notes of the previous CS to identify the
indication, type of uterine incision, and any peri-operative complications that may
require referral to a consultant obstetrician to consider an elective caesarean
section.
Women should be counselled about the maternal, perinatal and neonatal risks and
benefits of planned VBAC and ERCS when deciding the mode of delivery. The key
issues to include in the discussion are listed below.
Women considering VBAC should be informed that, according to the Royal College
of Obstetricians and Gynaecologists, the overall chances of a successful planned
VBAC are 72-76%1. Currently, the average success rate at this hospital is
60%.(16/17 data)
Previous vaginal birth, particularly previous VBAC, is the single best predictor for
successful VBAC and is associated with an approximately 85-90% planned VBAC
success rate1.
Women planning VBAC will remain midwife-led antenatally, unless other
complications requiring obstetric input arise.
Attendance at the VBAC class between 34 and 37 weeks should be recommended
Uterine rupture
The immediate risk that women planning a VBAC should be made aware of is uterine
rupture. Uterine rupture has an estimated incidence of 0.2 per 1000 maternities overall,
and can occur during pregnancy or labour.
The incidence in women undergoing planned VBAC is 1 in 500 ( or 99.8% safe)
maternities, while in women having an ERCS this risk is reduced to 1 in 3000 (or 99.97%
safe) maternities.
Although a rare outcome, uterine rupture is associated with significant maternal and
perinatal morbidity and perinatal mortality. The risk of uterine rupture may be greater
among those who have had two or more previous caesarean deliveries, or those who have
had a caesarean delivery less than 12 months previously, or in those whose labour is
being induced4. Uterine rupture may also occur after gynaecological surgery such as
myomectomy1
There are consequences to repeat LSCS which must be discussed when considering birth
options:
Future pregnancies
Women should be informed that ERCS increases the risk of serious complications in future
pregnancies. The following risks significantly increase with increasing number of repeated
caesarean deliveries: placenta praevia( it happens to 1 in 100 after 1 LSCS, 2 in 100 after
two and about 3 in 100 after three) , placenta accreta( will occur in1 in 7 to 1in 10 women
with a placenta praevia); injury to bladder, bowel or ureter; ileus; the need for
postoperative ventilation; intensive care unit admission; hysterectomy; blood transfusion
requiring four or more units and the duration of operative time and hospital stay1.
All women should be aware of:
Emergency CS
Women should be made aware that there is a risk of unplanned CS for both ERCS and
VBAC. 10% of women scheduled for ERCS go into labour before the 39 th week. Risk
factors for unsuccessful VBAC are: induced labour, no previous vaginal birth, body mass
index greater than 30 and previous caesarean for dystocia7.
Serious complications
Antepartum stillbirth
An extra 1in 1000 mothers with a prior LSCS will experience a stillbirth after 39 weeks
compared to mothers with no history of prior LSCs or stillbirth. The reasons are not known.
However, earlier delivery by ERCS or induction of labour is not recommended.
Hysterectomy
There is no evidence of higher risk of hysterectomy in the VBAC group compared to ERCS
group.
Hospital stay
The mean length of hospital stay is longer among women with ERCS when compared with
women who have a VBAC5. However, mothers who have an uncomplicated ERCS will
normally stay in hospital for only 1-2 nights.
Contraindications to VBAC1
Extended uterine incision at index LSCS (e.g. T or J shaped incisions)
Previous uterine rupture
Previous high vertical classical CS
Three or more previous CS deliveries
Previous myomectomy or prior complex uterine surgery
Women with a short interval between initial CS and VBAC and those known to have
fetal macrosomia should not be offered induction of labour unless agreed with a
consultant obstetrician
Augmentation
The guideline on the use of Oxytocin (GL925) should be followed:
Procedure
One Propess only - Consultant
IOL PG
authorisation required
Yes - Consultant authorisation
IOL ARM + Oxytocin
required
No - Authorisation required from
Augment dysfunctional labour
delivery suite Consultant
Augment 2° arrest No
For augmentation of SROM await 24 hours then augment with Oxytocin.
No Propess
Postnatal Care
Post-delivery, the woman should have the usual monitoring of maternal
observations, including vaginal loss. Digital palpation/ examination of scar is only
necessary if there is persistent postpartum bleeding.
Ideally Women who have not achieved a VBAC should be given the opportunity to
discuss the reasons for CS and be provided with both verbal and printed
information about birth options for future pregnancies.
Auditable standards:
1. VBAC pathway for all women with a prior history of one uncomplicated lower-
segment transverse CS, in an otherwise uncomplicated pregnancy at term, with no
contraindications to vaginal birth is to be followed.
3. All women who have had one previous CS will be given the VBAC leaflet on mode
of delivery by the 20 weeks appointment.
4. All women whose planned mode of delivery is VBAC will have a plan made should
the labour not commence as planned/post EDD at the 40 weeks appointment. This
will be documented on the VBAC counselling checklist and follow the agreed plan
for IOL as per guideline.
References
1. RCOG Green-top Guideline No.45. 2015. Birth after previous Caesarean birth.
2. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat
caesarean section versus planned vaginal birth for women with a previous
caesarean birth. Cochrane Database of Systematic Reviews 2004, Issue 4. No.:
CD004224. DOI: 10.1002/14651858.CD004224.pub2.
3. Guise JM, Eden K, Emeis C, et al. 2010. Vaginal birth after caesarean: new
insights. Evidence Report/Technology Assessment; 191:1-397
5. National Collaborating Centre for Women’s and Children’s Health 2011. Caesarean
section. NICE Full guideline.
8. Dexter SC, Windsor S, Watkinson SJ. Meeting the challenge of maternal choice in
mode of delivery with vaginal birth after caesarean section: a medical, legal and
ethical commentary. BJOG 2014;121:133-140Al-Zirqi I, Stray-Pedersen B, Forsén
L, Vangen S. Uterine rupture after previous caesarean section. BJOG
2010;117:809-820
10. Stone JL, Lockwood CJ, Berkowitz G et al (1984) use of cervical prostaglandin E2
in patients with previous CS.Br J Obstet Gynaecol 91: 7-10
11. Mackenzie IZ, Bradley S, Embrey MP(1997) Vaginal prostaglandins and labour
induction for patients previously delivered by caesarean section. Am J Perinatal 14:
157-160
12. Flamm BL, Anton D, Goings JR et al. (1987) prostaglandin E2 for cervical ripening:
multicenter study of patients with prior caesarean delivery. Obstet Gynecol 70: 709-
712
Appendix 2 – VBAC pathway for women with one previous CS at booking and no
additional risk factors requiring consultant led care