Article on Vaginal Birth After Caesarian Section

The following article was posted in the Belly Buddies Forum by Vanita - thought it might be more appropriate here!!

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Sorry bout the long post, but this is info on csec's and vbac's I thought you might be interested in!

3.10 MANAGEMENT OF VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC)
For the majority of women with a previous Caesarean birth a trial of labour should be encouraged. Less morbidity is encountered in women with successful VBAC compared those with elective repeat Caesarean birth. There are fewer blood transfusions, fewer postpartum infections and shorter hospital stays and have no increased perinatal mortality (Obstetric and Gynaecology clinics of North America 26(2) 295-304 1999 Jun).

A woman with a prior Caesarean is at increased risk regardless of her mode of birth.

A failed VBAC (non-elective Caesarean section in labour) has a higher rate of maternal and neonatal morbidity than a successful VBAC or an elective, repeat Caesarean.

The likelihood of uterine rupture with attempted VBAC is 0.5%. (0.2% uterine rupture, 1.1% asymptomatic dehiscence from case control studies). The risk of hysterectomy and perinatal death from uterine rupture are 0.05% and 0.07% respectively (Australian VBAC study) in hospitals equipped to provide rapid laparotomy. Uterine rupture with attempted VBAC after a classical Caesarean section is 5%.

Antenatal Management

An ultrasound scan should be performed to check placental localisation and to look for abnormal placentation.

Contra-Indications For VBAC

Absolute contraindications to VBAC:
 Previous classical caesarean section
 Previous inverted T uterine incision.
 Previous uterine rupture.
 Previous cephalo-pelvic disproportion (CPD) with anticipation of CPD in the current pregnancy. In order to make this diagnosis; the fetus must have been occipito anterior (OA) position, with secondary arrest of progress, and with significant moulding and caput of the fetal head.

Clinical or pelvimetry examination must also be used to confirm a small or abnormally shaped maternal pelvis, and the fetus must be anticipated to be comparable or larger in size than the previous baby.

 Lack of maternal decision after counselling with a Registrar or Consultant.
 Development since the previous delivery of a strong indication for elective Caesarean section.

Relative contraindications to VBAC:

1. Two or more previous Caesarean sections1.
2. Non cephalic presentation
3. Significant previous post Caesarean section sepsis.

Section B - 98

Counselling with regards to the surgical and anaesthetic risks, increased
thromboembolic disease and Respiratory Distress Syndrome in the neonate versus the risks of VBAC should be provided and carefully documented in the case notes.

The decision to proceed with induction of labour in women with a previous
Caesarean section should be discussed antenatally with the Senior
Registrar/Consultant. Induction of labour decreases the success rate of VBAC.

Intrapartum Management

Patients who have had a previous Caesarean section are not suitable for the Family Birth Centre

The patient should be advised to present to Delivery Suite early in labour.
Intravenous access should be established and blood taken for a group and hold serum or cross matching if appropriate.

The patient should be fasted.

Labour should be monitored using the partogram and any abnormalities should be notified to the registrar, who should perform an assessment.
Continuous fetal heart rate monitoring is mandatory. There is no contraindication to epidural analgesia Any delay in latent/active phase of labour or fetal heart rate abnormalities* should be discussed with the consultant Obstetrician on call for Delivery Suite with a view to Caesarean section.

*Abnormalities in the fetal heart trace, such as variable or late decelerations, prolonged fetal bradycardia, warrant Emergency Caesarean section without recourse to fetal scalp pH measurement. These abnormalities may be the first signs of scar rupture/dehiscence.

The available evidence suggests that the use of oxytocin is associated with a reduced success of vaginal birth and a doubling of scar rupture/dehiscence. However, oxytocin may be used with caution in women with a previous Caesarean section, following discussion with the consultant Obstetrician on call for Delivery Suite. Induction of labour with amniotomy/oxytocin and/or Foley catheter may be performed.
Prostaglandins are not licensed in Australia for use in patients with a uterine scar.

Be vigilant for the symptoms and signs of scar rupture, which may include

 Suprapubic tenderness and/or severe constant abdominal pain which continues between contractions
 Maternal tachycardia
 Vaginal bleeding

Section B - 99

 Fetal tachycardia or fetal heart decelerations
 No progress in labour
 Cessation of contractions

REFERENCES
1 American College of Obstetricians and Gynecologists. 1999.Vaginal birth after previous Cesarean delivery. Practice bulletin number 5. In ACOG 2002 Compendium of Selected Publications,
Washington DC: ACOG.
Dr J Ludlow
Review May 2000
Updated March 2001
Updated June 2003
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Vanita Chris
Tahlia Lakeisha 6yo
Rianna 17mth
EDD 22/07/05