Vaginal Birth After Caesarean (VBAC)

Last updated 20.09.12

 

Definition

-  Attempted vaginal delivery of pregnancy after previous LUSCS

 

Features

-  Scar from previous LUSCS is weakened area

-  If planning for a further 2 or more pregnancies VBAC reduces risk ass w repeat LUSCS

-  Success rate 50-85%

-  Previous vagnial birth 89%

-  Previous LUSCS for breech 86%

-  Previous LUSCS for placenta praevia 86%

-  Good prognostic factors

-  >12 months post prev LUSCS

-  No medical complications

-  BMI <30

-  Labour at <41/40

-  Baby <4000g

-  OA position

-  Spontaneous labour

-  Non recurring indication for LUSCS

-  PIH

-  Previous vagnial birth

-  Poor prognostic factors

-  IOL

-  BMI >30

-  Nil previous vagnial deliveries

-  Baby >4000g

-  Previous emergency LUSCS for FTP

-  Benefits over repeat LUSCS

-  Less blood loss

-  No surgical complications of LUSCS

-  Quicker recovery & shorter hospital stay

-  Decreased complications for further pregnancies

 

Indications

-  Previous LUSCS (one only)

-  No contraindication to vaginal delivery

 

Contraindications

-  Contraindications for vaginal delivery

-  Uterine surgery

-  Previous classical Caesarean section

-  Hysterotomy

-  LUSCS w J or T incision

-  Previous uterine rupture or dehescience

-  Multiple gestation: twins..

-  +/- macrosomia

-  +/- >2 previous LUSCS

 

Complications

-  Uterine rupture 0.5 – 0.7%

-  2% if x2 previous LUSCS

-  Emergency LUSCS

 

Mx

-  Antenatal

-  Obtain previous LUSCS report

-   LUSCS w J or T or classical

-  R/V abdominal scar

-  R/V prior to 36/40 to confirm suitability vs plan repeat elective LUSCS

-  Considered/cautious IOL

-   No Prostaglandins (Prostin, Cervadil) as increased risk of uterine rupture

-   Mechanical device more appropriate for cervical ripening

-   ARM is safe

-  +/- US of uterine scar

-  Post dates (>41/40) Mx

-   Twice weekly AFI & CTG

-   IOL vs elective LUSCS

-   If not for IOL then book backup LUSCS at 41-42/40 to allow maximum chance of spontaneous labour

-   If for IOL aim for 41+3 to 42/40 to allow maximum chance of spontaneous labour

-  Labour

-  IV access

-  FBE, Group & Hold

-  Continuous CTG once in established labour

-  VE

-   4/24 in 1st stage until 7cm

-   Then 2/24

-   Aim for 1cm/hr after 3cm

-  Consider ARM once 3cm, effaced & applied

-  Syntocinon only if D/W Consultant

-  2nd stage kept <2/24

-   1/24 for passive decent

-   Not >1/24 for active pushing

-  Maternal vitals 2/24+/-

-  Low threshold for emergency LUSCS

-  Not a contraindicaton for Epidural

 

 

 

References

 

RWH CPG: VBAC: Intrapartum Management, 25/02/13

RWH CPG: VBAC: Antenatal Management, 02/08/07

VBAC Patient Information (RWH)