Vaginal Birth After Caesarean (VBAC) Management post policy
Canberra Hospital and Health ServicesClinical Procedure Vaginal Birth After Caesarean (VBAC): ManagementContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc492896076 \h 1Purpose PAGEREF _Toc492896077 \h 2Alerts PAGEREF _Toc492896078 \h 2Scope PAGEREF _Toc492896079 \h 2Background PAGEREF _Toc492896080 \h 3Section 1 – Contraindications, benefits and risks PAGEREF _Toc492896081 \h 3Section 2 – Antenatal Management PAGEREF _Toc492896082 \h 6Section 3 – Intrapartum Management PAGEREF _Toc492896083 \h 7Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc492896084 \h 8References PAGEREF _Toc492896085 \h 9Search Terms PAGEREF _Toc492896086 \h 11PurposeTo provide clinical guidance to midwives and medical staff caring for and informing decision making for pregnant women who have had a previous caesarean section Back to Table of ContentsThis Standard Operating Procedure (SOP) describes for staff the process to ScopeAlertsPrevious pregnancy, labour and operation details such as location of uterine incision, previous birth weight and the intervening time between pregnancies will have a significant impact on decision making in subsequent pregnancies.Uterine rupture is a life threatening but extremely rare occurrence. Fear of outcomes such as uterine scar rupture can be a key motivation in a woman's decision making. Women need to be given evidence based, objective information based on their individual clinical assessment and their desired outcomes for this pregnancy when making decisions about subsequent labours and births.Experiencing a caesarean, especially in an emergency situation, can be traumatic for a woman and her partner. Her previous experience may impact on subsequent birth preparation. Women need to be offered the chance to debrief after their birth and may need further assistance and support.Regardless of whether a woman wishes to have an elective repeat Caesarean or whether she wants to attempt a VBAC, she should be booked into the Next Birth after Caesarean class (NBAC) in order to receive comprehensive evidence based information.Back to Table of ContentsScopeThis document applies to:Medical OfficersRegistered Midwives Student Midwives under direct supervisionBack to Table of ContentsBackgroundPregnant women with a history of a previous caesarean section should be fully informed about their choices of either a planned vaginal birth (VBAC) or elective repeat caesarean section. Risks and benefits should be discussed with respect to each option and in the context of the woman’s individual circumstances. The woman’s choice should be fully supported.70 – 80% of women who have had a previous caesarean section can safely plan to have a vaginal delivery with success rates of 40 – 80%. Higher success rates are associated with previous vaginal birth (80%), previous successful VBAC (94%), singleton/cephalic fetus, BMI <30, fetal weight <4000g, gestational age <40 weeks, spontaneous onset of labour, good progress in labour and preterm labour (the absence of any of these factors should not preclude attempting VBAC). RCOG, NIH 2010.Back to Table of ContentsSection 1 – Contraindications, benefits and risksContraindications:Any maternal medical condition that is a contraindication to vaginal birthAny obstetric condition that is a contraindication to vaginal birth (e.g. placenta praevia, vasa praevia). Previous uterine ruptureRelative contraindications: T or J incision (2% risk of rupture)Low vertical incision (2% risk of rupture) Previous classical caesarean section (9% risk of uterine rupture)Twins (same risk of rupture but less success rates) Known Macrosomia (>4000g)Shorter inter delivery interval (2 years)-increased risk of rupture (<1%)Need for prostaglandin induction of labour (2.5%)Previous myomectomy where the cavity is breachedPrevious hysterotomy A woman should be fully informed about the risks and benefits of each choice and the relevant increases if any for her particular circumstances:Benefits of successful VBAC:Avoidance of abdominal surgeryAvoidance of complications of multiple caesarean sections (see below)Reduction in neonatal respiratory complications (transient tachypnea of the newborn (TTN), asthma,)Lower maternal mortality (3.8 per 100 000 vs 13.4 per 100 00 for elective caesarean section)Shorter hospital stay (if BMI normal)Lower Venous thromboembolism (VTE) ratesSense of achievement and empowerment Feeling in control over decision makingImproved maternal-neonatal bondingImproved breastfeeding rateslower incidence of postnatal depressionLess painNo change in hysterectomy ratesRisks of VBAC:In the literature, many of the risks associated with VBAC are attributed to those who attempt a VBAC and are unsuccessful (risks of caesarean section):Maternal - Instrumental birth, perineal damageFetal Hypoxic ischaemic encephalopathy (0.8%)Perinatal mortality 0.4%Uterine rupture in labour 0.3%Most caesareans done in labours where the woman attempted a VBAC are performed for fetal distress/ abnormal cardiotocograph (CTG) or delay in progress or maternal choice where the woman changes her mind in labour and elects for a caesarean.Uterine Rupture:Alert:Uterine rupture is a catastrophic but rare event. The risk increases if labour is induced with prostaglandins or if oxytocin is used injudiciously without careful monitoringTypes of uterine ruptureCatastrophic: the scar separates and there is extrusion of the fetus into the abdominal cavity. There may be significant maternal bleeding leading to shock and /or severe fetal compromise leading to death or hypoxic ischaemic encephalopathy (HIE).Scar dehiscence: (more commonly) the scar widens or opens partially (dehisces), the amnion remains intact, and there is little, if any, maternal or fetal compromise. This dehiscence may be undetected and is usually only identifed if a caesarean is performed. The risk of catastrophic uterine rupture varies: multiparous with no previous caesarean section 0.05% – 0.2%women planning a VBAC 0.3% - 0.7%. planned elective caesarean section prior to labour Induction of labour <37 weeksInduction of labour post datesAfter 2 previous caesarean sections augmentation with oxytocinThere is no single clinical feature that is associated with the onset of uterine rupture. In the event of a uterine rupture an abnormal CTG is the most consistent finding (BMJ 2004).Any of the following may be found on history or examination: Vaginal bleedingHaematuriaSudden cessation of uterine activity, loss of uterine toneMaternal tachycardia, hypotension, shock, confusionMovement of fetal presenting part to a higher station, reduction in cervical dilatationAbnormal CTG – e.g. fetal bradycardiaSevere constant abdominal pain, especially persistent between contractionsChest, shoulder tip, hip or back pain, shortness of breathAcute onset of pain over scarRisks of elective repeat caesarean section:Increased risk of serious (life threatening) complications in future pregnancies with each caesarean section:Placenta praeviaPlacenta accreta, percretaOrgan injury – bowel, bladder, ureter.IleusBlood transfusionsThromboembolic disease (DVT and pulmonary embolism)Infections (especially wound)Risks of elective repeat caesarean section for the neonate:Increased risk of short and long term neonatal respiratory complications – TTN, respiratory distress syndrome (RDS), ventilation, asthma (4%)Interference with bondingPotential delay in breastfeedingInjuries (lacerations/bruising/fractures)Benefits of elective repeat caesarean section:Reduction in perinatal morbidity and mortality (mostly due to avoidance of prolonged gestation)Avoidance of perineal trauma (small reduction in prolapse, fecal incontinence, stress incontinence)Planned and known date – 10% of women come into labour prior to their planned elective date Back to Table of Contents Section 2 – Antenatal ManagementWomen with a history of a previous caesarean section should have consultation with a medical officer in line with the Australian College of Midwives (ACM) National Guidelines for Consultation and Referral.Preadmission visit:At the pre admission visit with the midwife, a woman with a history of a previous caesarean section is identified and a referral to the NBAC class is recommended. The relevant section of the pathway is completed by the midwife, including a discussion on the woman’s expectations of mode of birth for the current pregnancy. She is given verbal and written information on VBAC as per the background information above, and booked into an NBAC education session, hopefully before 20 weeks.The midwife will also identify if previous medical records are available and if not, request a copy from the appropriate institution.The woman will be booked in for medical review after attending the NBAC class to discuss her options.Medical review with specialist/registrar approx 20 weeks:The current pregnancy will be reviewed. Women being cared for through Continuity of midwifery care programs require discussion at collaborative practice meeting.Early identification of any current pregnancy complications that may impact on the woman’s decision should be identified. Her past clinical history should be reviewed including number of previous caesarean sections, gestation and reason for previous caesarean section(s) as per the pathway. Information should be obtained about the previous caesarean section(s) including:Reason for previous caesarean and labour complicationsDilatation and fetal station at caesareanBaby’s birth weight and head circumferenceBaby’s positionType of uterine incisionType of uterine closure Any relevant intraoperative complications (extension, conversion to J or T, B Lynch)Post partum complications.There should be a discussion on the risks and benefits of VBAC, and a discussion on her suitability for VBAC in context of her individual circumstances.Knowledge of the woman’s intended number of future pregnancies should be an important factor to consider when discussing her options for vaginal birth after caesarean section or elective repeat caesarean section.She should be offered an ultrasound if clinically indicated to be performed in the third trimester.The pregnancy continues as per routine antenatal care with review again at 36 weeks.36 week visit with the specialist/registrar:At 36 week visit with the registrar or specialist, the decision to proceed with VBAC is confirmed again in the context of the woman’s individual circumstances. Any relevant new pregnancy issues arising since last review need to be discussed and any relevant ultrasounds reviewed. The birth plan is discussed.The woman should be made aware that in labour it will be recommended that she has:An IV cannula; to allow immediate access should there be signs of compromise Continuous Electronic Fetal monitoring to ascertain baby's wellbeing and response to the labourRegular vaginal examinations in established labour to ensure the labour is progressing. In the event of the woman opting for elective caesarean section, the procedure is booked at the 36 week visit to occur after the 39th week of pregnancy. 40 and 41 week visit with the specialist/registrar:At 40 and 41 weeks, the woman is reviewed by a medical officer and her decision to proceed with attempt at VBAC is once again discussed. At this time an examination per vagina is offered and a plan for induction of labour or elective caesarean section is discussed and organized. If the woman wishes to proceed with induction of labour the increased risks need to be discussed along with the reduced success rates in the context of the benefits of vaginal birth. She may be offered an Artificial Rupture of Membranes (ARM) or if her cervix is not favourable, a balloon catheter.The woman needs to be aware that should she not labour spontaneously with an ARM, oxytocin may be offered for a limited period of time. Back to Table of Contents Section 3 – Intrapartum ManagementWhen a woman who has had a previous caesarean section presents in labour:Review the woman’s antenatal record and confirm with the woman that she is planning a vaginal birth.Recommend continuous electronic fetal monitoring (CEFM) during established labour, and as per antenatal discussion. Some women may find that CEFM restricts their movements in labour, discuss the option of using telemetric monitoring or fetal scalp electrode to facilitate monitoring whilst allowing position changes. Obtain IV access and group and hold.Women planning a VBAC may labour in the bath using telemetry as long as the baby can be safely monitored and there is ability to rapidly get the woman out of the bath if an emergency arises.Women should be encouraged to remain upright, active and well hydrated in labour to encourage effective contractions and optimise fetal positioning. Women should also be encouraged to empty their bladder regularly.Women having a VBAC may use all the non pharmacological and pharmacological pain relief options that are available to those having a non VBAC labour including an epidural block if requested. An epidural is not thought to mask scar pain.Oxytocin may be used for augmentation or induction of labour (IOL) with caution and only after discussion and under supervision of consultant.The woman will be offered regular vaginal examinations to assess the progress of labour; as a delay in progress with regular strong contractions and a well positioned baby may again indicate scar compromise. A poorly positioned baby may increase the woman's chance of an obstructed labour.It is recommended that the woman get out of the bath for second stage but may use the shower, hot packs and warm perineal compresses as per usual labour care.Third stage will be managed according to the Labour Care 1st 2nd and 3rd stage Guideline.Back to Table of Contents Related Policies, Procedures, Guidelines and LegislationPoliciesHealth Directorate Nursing and Midwifery Continuing Competence Policy, DGD12-050Consent and treatmentProceduresCHHS Healthcare Associated Infections Clinical Procedure, CHHS15/072CHHS Patient Identification and Procedure Matching Policy, CHHS14/051Guidelines Labour care 1st, 2nd and 3rd stageFetal surveillanceLegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferences ADDIN EN.REFLIST 1.NSW Ministry of Health. Maternity - Towards Normal Birth in NSW [Electronic]. Sydney, Australia: NSW Government; 2010 [cited 2017 22 April]. Available from: T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GML. Caesarean section for non-medical reasons at term. Cochrane Database of Systematic Reviews. 2012.3.Who. WHO statement on caesarean section rates. WHO; 2015.4.Hyde MJ, Mostyn A, Modi N, Kemp PR. The health implications of birth by Caesarean section. Biological Reviews. 2012;87(1):229-43.5.Fitzpatrick KE, Kurinczuk JJ, Alfirevic Z, Spark P, Brocklehurst P, Knight M. Uterine Rupture by Intended Mode of Delivery in the UK: A National Case-Control Study. PLOS Medicine. 2012;9(3):e1001184.6.Fawsitt CG, Bourke J, Greene RA, Everard CM, Murphy A, Lutomski JE. At What Price? A Cost-Effectiveness Analysis Comparing Trial of Labour after Previous Caesarean versus Elective Repeat Caesarean Delivery. PLoS ONE. 2013;8(3):e58577.7.Gilbert SA, Grobman WA, Landon MB, Varner MW, Wapner RJ, Sorokin Y, et al. Lifetime Cost-Effectiveness of Trial of Labor After Cesarean in the United States. Value in Health. 2013;16(6):953-64.8.Declercq E, Barger M, Cabral HJ, Evans SR, Kotelchuck M, Simon C, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstetrics and Gynecology. 2007;109(3):669-77.9.Dodd JM, Crowther CA, Huertas E, Guise J-M, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews. 2013(12).10.Homer CSE, Johnston R, Foureur MJ. Birth after caesarean section: changes over a nine-year period in one Australian state. Midwifery. 2011;27(2):165-9.11.Royal College of Obstetricians and Gynaecologists. Birth after Previous Caesarean Birth: Green-top Guideline No. 45. London, United Kingdom: RCOG; 2015 [cited 2017 22 April]. Available from: Health. Maternity services at the Centenary Hospital for Women and Children [Electronic]. Canberra Australia: ACT Government; 2017 [updated 21 April 2017; cited 2017 21 April]. Available from: S, Griffiths M. Vaginal birth after two caesarean sections (VBAC‐2)—a systematic review with meta‐analysis of success rate and adverse outcomes of VBAC‐2 versus VBAC‐1 and repeat (third) caesarean sections. BJOG: An International Journal of Obstetrics & Gynaecology. 2010;117(1):5-19.14.NICE. Caesarean section - clinical guideline 132. National Institute for Health and Clinical Excellence; 2014.15.Lundgren I, van Limbeek E, Vehvilainen-Julkunen K, Nilsson C. Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a qualitative study from countries with high VBAC rates. BMC Pregnancy and Childbirth. 2015;15(1):196.16.Mone F, Harrity C, Toner B, McNally A, Adams B, Currie A. Predicting why women have elective repeat cesarean deliveries and predictors of successful vaginal birth after cesarean. International Journal of Gynecology & Obstetrics. 2014;126(1):67-9.17.Schoorel ENC, van Kuijk SMJ, Melman S, Nijhuis JG, Smits LJM, Aardenburg R, et al. Vaginal birth after a caesarean section: the development of a Western European population-based prediction model for deliveries at term. BJOG: An International Journal of Obstetrics & Gynaecology. 2014;121(2):194-201.18.Dahlen HG, Homer CSE. ‘Motherbirth or childbirth’? A prospective analysis of vaginal birth after caesarean blogs. Midwifery. 2013;29(2):167-73.19.Gardner K, Henry A, Thou S, Davis G, Miller T. Improving VBAC rates: the combined impact of two management strategies. Australian & New Zealand Journal of Obstetrics & Gynaecology. 2014;54(4):327-32.20.Knight HE, Gurol-Urganci I, van der Meulen JH, Mahmood TA, Richmond DH, Dougall A, et al. Vaginal birth after caesarean section: a cohort study investigating factors associated with its uptake and success. BJOG: An International Journal of Obstetrics & Gynaecology. 2014;121(2):183-92.21.Catling-Paull C, Johnston R, Ryan C, Foureur MJ, Homer CSE. Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review. Journal of Advanced Nursing. 2011;67(8):1662-76.22.Lundgren I, Healy P, Carroll M, Begley C, Matterne A, Gross MM, et al. Clinicians’ views of factors of importance for improving the rate of VBAC (vaginal birth after caesarean section): a study from countries with low VBAC rates. BMC Pregnancy and Childbirth. 2016;16:350.23.Farnworth A, Robson SC, Thomson RG, Watson DB, Murtagh MJ. Decision support for women choosing mode of delivery after a previous caesarean section: A developmental study. Patient Education and Counseling. 2008;71(1):116-24.24.McGrath P, Phillips E, Vaughan G. Vaginal birth after Caesarean risk decision-making: Australian findings on the mothers' perspective. International journal of nursing practice. 2010;16(3):274-81.25.Shorten A, Shorten B, Kennedy HP. Complexities of Choice after Prior Cesarean: A Narrative Analysis. Birth: Issues in Perinatal Care. 2014;41(2):178-84.26.White HK, May A, Cluett ER. Evaluating a Midwife‐Led Model of Antenatal Care for Women with a Previous Cesarean Section: A Retrospective, Comparative Cohort Study. Birth. 2016;43(3):200-8.27.Tolmacheva L. Vaginal birth after caesarean or elective caesarean--What factors influence women's decisions? British Journal of Midwifery. 2015;23(7):470-95.28.Black M, Entwistle VA, Bhattacharya S, Gillies K. Vaginal birth after caesarean section: why is uptake so low? Insights from a meta-ethnographic synthesis of women's accounts of their birth choices. BMJ Open. 2016;6(1).29.Martin T, Hauck, Y., Fenwick, J., Butt, J., Wood, J. . Evaluation of a next birth after caesarean antenatal clinic on women’s birth intention and outcomes, knowledge, confidence, fear and perceptions of care. Evidence Based Midwifery. 2014;12(1):11-5.30.McLachlan HL, Forster DA, Davey MA, Farrell T, Gold L, Biro MA, et al. Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology. 2012;119(12):1483-92.31.Homer CS, Besley K, Bell J, Davis D, Adams J, Porteous A, et al. Does continuity of care impact decision making in the next birth after a caesarean section (VBAC)? a randomised controlled trial. BMC Pregnancy and Childbirth. 2013;13(1):140.32.Robson S, Campbell B, Pell G, Wilson A, Tyson K, Costa C, et al. Concordance of maternal and paternal decision-making and its effect on choice for vaginal birth after caesarean section. Australian & New Zealand Journal of Obstetrics & Gynaecology. 2015;55(3):257-61.33.Chen MM, Hancock H. Women's knowledge of options for birth after Caesarean Section. Women and Birth. 2012;25(3):e19-e26.Back to Table of ContentsSearch Terms VBAC, NBAC, Caesarean, Uterine rupture, Vaginal Birth After Caesarean, Next Birth After CaesareanDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC Chair ................
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