Vaginal Birth after Caesarean Birth (VBAC) (415)

ANTENATAL CLINIC

• An individualised risk assessment should be made for each woman and full documentation of birth preferences made in the notes.
• Previous notes should be reviewed. If not available or the woman birthed in another unit, then information regarding her previous births should be sought early in the antenatal period.
• Obstetric Consultant input during the antenatal period should be offered / arranged at the 15-16week appointment.
• The woman should be given the current RCOG Patient Leaflet on BAC and the GGC Planned Caesarean Birth leaflet early in her antenatal care and invited to return with any questions at a subsequent clinic appointment.
• Women should be provided with the evidence not only of the risks involved, but also the positive aspects of VBAC and the lower morbidity rates.
•  Any woman considering IOL after a previous Caesarean Birth should be reviewed by their consultant. She is entitled to seek a second opinion.

When is Planned Repeat Caesarean Birth the optimal choice?

• Offer planned CB to all women with a classical scar. “T” or inverted “T” incisions and extensions of uterine scars that have a vertical component (i.e. not “lateral LUS extensions”).
• Offer CB to women from overseas with vertical midline abdominal scars and who cannot be sure that they had a transverse lower segment uterine incision.
• Offer CB to women who have absolute contraindications such as placenta praevia.
• An individualised care plan should be taken in the following circumstances in light of factors that may increase the risk of uterine rupture: short inter-birth interval (<12 months), >41 weeks gestation, maternal age >40, obesity, macrosomia, twins.
• Previous hysterotomy or myomectomy entering uterine cavity should be assessed by an obstetric consultant to consider individual situation.

Later antenatal care

• Check that ultrasound localisation of placental site has been performed by 32 weeks.
• Record plan in notes prior to admission: Whilst Consultant agreement is not needed, documentation should include the date of discussion, topics discussed, and the members of the MDT who contributed to the discussion. Consider if a woman’s risk profile has changed during her pregnancy.
• Discuss VBAC again to ensure no new issues.
• Await spontaneous labour and advise woman to contact maternity triage when she has regular or painful uterine activity: she will be advised to attend for assessment and management plan.
• Review at 41 weeks: Offer cervical assessment and discuss risks of IOL in VBAC cases, dependent on method used. Make plan for either IOL or planned Repeat Caesarean Birth. If the choice for a planned repeat caesarean birth has been made by the woman, a plan including the planned birth date should be documented in the notes together with a plan, should she labour prior to that date.
• If a woman wishing VBAC presents with prelabour rupture of membranes she should be reviewed/discussed with the on-call consultant and an individual plan made.
• All women wishing VBAC should be reviewed by medical staff when attending maternity triage in labour or with SROM.

• Inform on call Consultant of admission in labour if any other risk factors or concerns.
• Medical review of woman and case notes/ Badgernet. Determine that there are no new contra-indications to VBAC. 
• Confirm VBAC request remains appropriate and that woman wishes this.
• Recommend birth in unit with access to theatre. If the woman has chosen to birth in freestanding midwife unit, community maternity unit or at home, labour dystocia requires senior review.
• There should be rigorous adherence to routine maternal observations.
• Continuous fetal heart rate monitoring is advised, commencing at the onset of regular uterine activity. If the woman declines this, inform the on-call Consultant and carefully document the details of the discussion between all parties.
• One to one midwifery care in labour is standard for all birthing women.
• Early IV access recommended.
• FBC, Group and Save (only cross match if specific indication – See Blood Ordering Schedule (ObstetriCB)).
• Alert Anaesthetic registrar to VBAC. Epidural anaesthesia is not contraindicated in a VBAC labour, although the sudden requirement for increase in analgesic need may herald uterine rupture and usually needs a senior review.

FIRST STAGE: 

• Labour progress should be monitored on the basis of vaginal examination at least every 4 hours.
• “Uterine inefficiency / incoordinate activity / abnormal contraction pattern” should all prompt careful consideration of entire case and whether VBAC attempt should be continued.
• First line for IOL after 41wks gestation should be inpatient Cooks Balloon. With mechanical methods (cervical ripening balloon, or amniotomy) the chance of rupture is 8 per 1000. If prostaglandins are used the chance of rupture is 24 per 1000. The use of augmentation by ARM and / or syntocinon must only be considered after a critical review of case and after discussion with Consultant Obstetrician (or equivalent). Women should be informed of there is a 15 per 1000 (1.5%) risk of uterine rupture if induced or augmented (still very rare). The risk with Prostin is thought to be higher and therefore not routinely recommened. Syntocinon dose and rate increases are specified in relevant guideline and are lower than those used in primagravida’s (see Syntocinon guideline).
  
  HEED WARNING SIGNS:

• Slow progress: first or second stage.
• Fetal Tachycardia.
• Atypical severe pain, especially if persisting between contractions: rupture can be preceded by all degrees and patterns of pain.
• Previously effective epidural, now with scar pain.
• Unexplained Maternal Tachycardia, hypotension, fainting.
• Vaginal Bleeding.
• Haematuria.
• Abnormal CTG.
• Cessation of previously efficient uterine activity.
• Loss of station of presenting part / change in abdominal contour.

SECOND STAGE: 

• This should be progressive and critical evaluation made after one hour.
• Routine debrief should be offered on postnatal ward if outcome is CB, providing reasons for CB and implications for future pregnancies.

Birth after Caesarean (VBAC vs ERCB) form