Skip to main content
  1. Right Decisions
  2. Maternity & Gynaecology Guidelines
  3. Maternity
  4. Back
  5. Antenatal, general
  6. Vaginal Birth after Caesarean Section (VBAC) (415)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Vaginal Birth after Caesarean Section (VBAC) (415)

Warning Warning: This guideline is 495 day(s) past its review date.
Please report any inaccuracies or issues with this guideline using our online form

Pregnancy and childbirth following Caesarean Section:

The decision about mode of birth should consider:

  • Maternal preferences and priorities.
  • The woman’s past obstetric history.
  • General discussion of the overall risks and benefits of Vaginal Birth after Caesarean Section (VBAC) and Elective Repeat Caesarean Section (ERCS).
  • All women suitable for VBAC should be offered this option

Women who want VBAC should be supported and:                                

  • Be informed that women who labour spontaneously with a previous section but without a previous vaginal birth have a 72-75% chance of a vaginal birth.
  • Be informed that women who labour spontaneously with both previous CS and a previous vaginal birth are more likely to give birth vaginally with an 85-90% chance of success.
  • Be informed that uterine rupture is very rare but increased with VBAC: about 1 per 10,000 repeat CS and 50 per 10,000 (1 in 200) VBAC.
  • Be informed that intrapartum infant death is rare (about 10 per 10,000 – the same as the risk for women in their first pregnancy), but increased compared with planned repeat CS (about 1 per 10,000).
  • Be advised to have electronic fetal monitoring during labour: indicating this is unit policy if VBAC attempted.
  • Should labour in a unit where there is immediate access to CS and on-site blood transfusion.
  • If having induction of labour should be aware of the increased risk of uterine rupture (80 per 10,000) if mechanical methods (amniotomy or Foley’s catheter) are used compared to 240 per 10,000 if prostaglandins are used).

ANTENATAL CLINIC

  • An individualized risk assessment should be made for each woman and full documentation of delivery plan made in the notes.
  • Previous notes should be reviewed. If not available or the woman delivered in another unit then information regarding her previous deliveries should be sought early in the antenatal period.
  • Consultant input during the antenatal period should be offered / arranged.
  • The woman should be given the current RCOG Patient Leaflet on VBAC and the GGC Elective Caesarean Section leaflet early in her antenatal care and invited to return with any questions at a subsequent clinic appointment.
  • Consultant opinion should be sought regarding their preferences about IOL in VBAC cases BEFORE discussion with woman. Ideally, any woman considering IOL after a previous Caesarean Section should be reviewed by their consultant. She is entitled to seek a second opinion.
  • Women who have had two or more caesarean sections should be counselled by a senior obstetrician. This counselling should include detailed risks of uterine rupture and maternal morbidity. We would not usually offer these women IOL.
  • A plan should be documented in the casenotes by 34 weeks at the latest.
  • Complete and sign the Birth after Caesarean (VBAC vs ERCS) form (Appendix 1)

When is Elective Repeat Caesarean Section the optimal choice?

  • Offer elective CS to all classical UTERINE scars, ”T” or inverted “T” incisions and extensions of uterine scars that have a vertical component (i.e. not “lateral LUS extensions”).
  • Offer CS to women from overseas with vertical midline abdominal scars and who cannot be sure that they had a transverse lower segment uterine incision.
  • Offer CS to women who have absolute contraindications such as placenta praevia.
  • Consider factors that may increase the risk of uterine rupture – short inter-delivery interval (<12 months), post-date pregnancy, maternal age >40, obesity, macrosomia, twins.

Later antenatal care

  • Check that ultrasound localisation of placental site has been performed by 32 weeks.
  • Record Plan in notes PRIOR to Admission: document DATE and agreement of Consultant. Discuss VBAC again to ensure no new issues.
  • Await spontaneous labour and advise woman to contact Maternity Assessment Unit 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 Elective Repeat Caesarean Section. If the choice for an elective repeat Caesarean section has been made by the patient, a plan including the section date should be documented in the notes together with a plan should she labour prior to her Caesarean section 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 MAU in labour or with SROM.

  1. Medical review of woman and case notes/ Badgernet. Determine that there are no new contra-indications to VBAC. 
  2. Confirm VBAC request remains appropriate and that woman wishes this.
  3. There should be rigorous adherence to routine maternal observations.
  4. 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).
  5. Obtain IV access.
  6. FBC, Group and Save (only cross match if specific indication – See Blood Ordering Schedule (Obstetrics)).
  7. 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.
  8. FIRST STAGE: Labour should be progressive 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.
    • 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 the 2-3 fold risk of uterine rupture (although still very rare) and 1.5 fold increased risk of caesarean section when involving induction or augmentation of labour.
    • 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.
    • Atypical severe pain, especially if persisting between contractions: rupture can be preceded by all degrees and patterns of pain,.
    • Unexplained Maternal Tachycardia, hypotension, fainting.
    • Vaginal Bleeding.
    • Abnormal CTG.
    • Cessation of previously efficient uterine activity.
    • Loss of station of presenting part / change in abdominal contour.
  1. SECOND STAGE: This should be progressive and critical evaluation made after one hour.

Birth after Caesarean (VBAC vs ERCS) form

Editorial Information

Last reviewed: 08/11/2018

Next review date: 30/11/2023

Author(s): Julie Murphy.

Version: 3

Approved By: Obstetrics Clinical Governance Group

Document Id: 415

Related guidelines
References

www.nice.org.uk/CG013fullguideline

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_45.pdf RCOG Green top guideline No. 45 Birth after Previous Caesarean Birth October 2015