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.

Background

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

Antenatal Counselling

• Review old notes pertinent to the previous LSCS - directly or by

correspondence with other hospital
• Initial discussion with patient (review the labour that resulted in LSCS;
discuss outcomes for VBAC - unit specific; offer appropriate
information leaflet; plan VBAC for majority)
• Record final agreed plan for delivery in antenatal record (Consultant
should be involved in this decision) - this may be nearer term.

Induction of Labour in cases of VBAC

 • The risk of uterine rupture is increased in induced labour compared to
spontaneous labour and this increase is more marked if both
prostaglandin (PG) and oxytocin are used (3).

Therefore:
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

ONSET Amniotomy - should be considered when the cervix

(ARM) 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
FIRST FH monitoring - continuous electronic FH monitoring
STAGE 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 - 4 hourly up to 7cm dilatation & 2
examination 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)
SECOND Length - with epidural, if maternal and fetal
STAGE 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
THIRD Uterine scar - the integrity of the uterine scar does
STAGE not need to be checked
routinely
- D/W consultant if: a) there is
persistent or excessive vaginal
bleeding post-delivery or b) if there are
concerns about scar
integrity

Special Points

Length of labour - inform consultant when appropriate oxytocin

(VBAC) augmentation
does not correct progress of labour. This review and
discussion
should be done earlier rather than later (5).
Intrauterine - routine use of IUP does not improve obstetric
pressure (IUP) outcome (6) or
monitoring reduce scar rupture rate. - if available, consider IUP
in oxytocinon-augmented labour when contractions
are difficult to assess or monitor (eg obese patients)
- using the 'active contraction area' per 15 minutes -
aim for
pressures near to the mean pressure in normal
labour =
1099 kPas/15 mins (7). [Normal range = 700 - 1500
kPas/15 mins
(10th - 90th centiles)].
Scar dehiscence & Symptoms and signs of impending rupture include:
rupture * rising maternal pulse rate (MAY BE THE
ONLY SIGN)
* acute fetal heart rate abnormalities
* sudden cessation of contractions
* continuous scar pain (still occurs with epidural)
* vaginal bleeding
* haematuria
* retraction of presenting part (on vaginal
assessment)

- ALL STAFF must be aware of these symptoms &

signs
- they may occur for the first time in the SECOND
STAGE
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.

References

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.