Vaginal Birth After Caesarean Section (VBAC)

Care should be in line with the RCOG Greentop Guideline on this subject.

Women who have had one previous uncomplicated lower uterine segment transverse caesarean section in an uncomplicated pregnancy, with no contraindications to vaginal birth after caesarean section (VBAC), should be offered antenatal counselling on planned VBAC. Any decisions should be documented in the notes.  

Counselling should include

• success rates of planned VBAC are around 75%, and around 90% in those who have had a previous vaginal delivery
• there is a 1-2% reduction in post-natal respiratory problems with VBAC compare to elective repeat LUSCS
• elective repeat LUSCS may increase risk of serious complications in subsequent pregnancies (placenta praevia, placenta increta, and injury to bladder or bowel) .
• risk of uterine rupture in VBAC is around 1:200, and probably less if oxytocics are avoided. Uterine rupture can be associated with perinatal injury or loss. 
• An information leaflet should be offered to support the counselling.

Notes:

• Planned VBAC in preterm women has similar success rates to those at term but reduced risk of uterine rupture
• Contra-indications to VBAC are
• Previous uterine rupture
• Previous vertical incision classical caesarean section (high risk of rupture)
• Three or more LUSCS
• Epidural analgesia is not contra-indicated.

Women with a prior history of two uncomplicated LUSCS in an uncomplicated pregnancy, with no contraindications to VBAC who have been fully informed by an appropriately trained obstetrician may be considered suitable for planned VBAC. There is no recognised increased rate of uterine rupture at this stage compared with one previous LUSCS.

Intrapartum care

• An intravenous line in situ and bloods taken for group and save.
• Continuous fetal monitoring following onset of uterine contractions for the entire duration of the labour (abnormal CTG findings present in around two thirds of cases of uterine rupture)
• Signs of rupture include:
  • Abnormal CTG
  • Severe abdominal pain between contractions
  • Chest/shoulder tip pain
  • Sudden onset of shortness of breath
  • Vaginal bleeding/haematuria
  • Cessation of efficient uterine activity
  • Maternal tachycardia/hypotension/shock
  • Loss of station of presenting part

Induction and augmentation with VBAC

Induction and augmentation of labour should only be carried out with direct consultant involvement, and ideally with a balloon to minimise the chance of scar rupture.

Syntocinon should  only be used after consultation with a  Consultant.

Syntocinon augmentation should be titrated such that it should not exceed the maximum rate of 4 contractions per 10 minutes