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Title: Management of vaginal birth after caesarean (VBAC)

Version Number as from December 2004: 1

Document Type: Clinical guideline

Scope: Maternity Classification: Clinical guideline

Author: S Das, Consultant Obstetrician & Gynaecologist

Groups Consulted: See consultation list

Validated By: Women’s Quality Forum

Equality Impact Assessed: Yes Date: Jan 2010

Description of amendments (if appropriate) :

Authorising Body: Clinical Safety & Quality Improvement Committee

Date of Authorisation: 18 June 2010

Master Document Controller: K Webber, WQF Secretary

Review Date: Jan 2013

Key Words: VBAC, induction of labour, oxytocin

CONTENTS

1. Purpose and Scope of document .......................................................... 2

2. Definition ............................................................................................... 2

3. Document Statement ............................................................................ 2

4. Monitoring, Evaluation & Review ........................................................... 5

5. References ............................................................................................ 5

6. Equality Impact Assessment ................................................................. 9

7. Consultation List .................................................................................. 14

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FAMILY CARE DIVISION

GUIDELINE FOR MANAGEMENT OF VAGINAL BIRTH

AFTER CAESAREAN (VBAC) 1. Purpose and Scope of document This document provides guidance for management of birth for pregnant women following previous caesarean section birth.

2. Definition VBAC refers to any woman who has experienced a prior caesarean birth who plans to deliver vaginally rather than by repeat caesarean section. Successful and unsuccessful planned VBAC:

• A vaginal birth (spontaneous or assisted) in a woman undergoing planned VBAC indicates a successful VBAC.

• Birth by emergency caesarean section during the labour indicates an unsuccessful VBAC.

• Overall chances of successful planned VBAC after a single previous caesarean is 72–76%.

3. Responsibilities of Staff Groups

Midwives are responsible for referring the women to a Consultant clinic following her risk and needs assessment. The midwives should provide support and information for the women in order to enable the decision making process. The midwife should carry out the management plan as documented by the obstetrician. The obstetrician are the lead professionals and should provide information and care to, documenting all information on the proforma (appendix 1).

4. Document Statement Antenatal Care:

• Women with a prior history of one uncomplicated lower-segment transverse caesarean section, in an otherwise uncomplicated pregnancy at term, with no contraindication to vaginal birth, should be able to discuss the option of planned VBAC and the alternative of a repeat caesarean section.

• At booking visit, detailed events of the previous birth and postnatal period should be taken into consideration

• A final decision for mode of birth should be agreed between the woman and her Consultant or senior middle-grade doctor at booking visit unless woman is undecided. In this case, decision should be documented by 36 weeks gestation or earlier.

• If consultant is unavailable in clinic, the completed notes should be left for review later

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• There should be documented individual management plan for labour for the woman

• Prior plan for VBAC may change in light of evolving problems during pregnancy that may preclude VBAC.

• Any change should be documented in both hand-held and back-up notes.

• A plan for the event of labour starting prior to term (< 37 weeks) should be documented.

• Plan and method of induction should be clearly documented should pregnancy continue beyond 40 weeks.

• This may be planned at clinic visit at 40+ weeks by the consultant or senior middle-grade doctor.

• The antenatal counselling of all women with one previous caesarean birth should be documented in the checklist and filed in the backup notes (appendix1)

Caution: • women with twin gestation • fetal macrosomia • short inter-delivery interval • PPROM/ SROM in current pregnancy • Other associated obstetric /medical / surgical conditions

Plan for induction/ augmentation in above cases should be made by Obstetric Middle grade doctor or Consultant Contraindications to VBAC:

• Women with a prior history of one classical caesarean section. • Women with a previous uterine incision other than an uncomplicated

low transverse caesarean section incision who wish to consider vaginal birth should be assessed by a consultant or senior middle-grade doctor with full access to the details of the previous surgery.

Risks and benefits of VBAC: (points for counselling)

• VBAC carries a risk of uterine rupture of 22–74/10,000. • Planned VBAC compared with repeat CS carries around 1% additional

risk of either blood transfusion or endometritis. • VBAC probably reduces the risk that their baby will have respiratory

problems after birth (2–3% with planned VBAC and 3–4% with repeat CS).

• The risk of anaesthetic complications is extremely low, irrespective of planned VBAC or repeat CS.

• Repeat CS may increase the risk of serious complications in future pregnancies.

Induction and augmentation:

• There is 2-3 fold increased risk of uterine rupture and around 1.5-fold increased risk of caesarean section in induced and/or augmented labour compared with spontaneous labour


• There is a higher risk of uterine rupture with induction of labour with prostaglandins.

• Risk of uterine rupture with prostaglandin induction: 87/ 10,000 • Risk of uterine rupture with non- prostaglandin induction (balloon):

29/10,000 • The decision to induce, the method chosen, the decision to augment

with oxytocin, the time intervals for serial vaginal examination and the assessment of progress that would necessitate and advise on discontinuing VBAC should be discussed with the woman by the named / or attending consultant obstetrician (Consultant-of-week or on-call).

Intrapartum care:

• Planned VBAC should be conducted in CDS, with continuous electronic monitoring.

• IV access and FBC, G&S • Epidural anaesthesia is not contraindicated in planned VBAC. • Women insisting on home birth should be carefully counselled by the

consultant. • Arrange appointments with Community midwife matron for organizing

support and drawing detailed plan of limiting factors for referral to CDS. Indicators of scar dehiscence/ rupture:

• abnormal CTG • severe abdominal pain, especially if persisting between contractions • chest pain or shoulder tip pain • sudden onset of shortness of breath • acute onset scar tenderness despite good epidural • abnormal vaginal bleeding or haematuria • cessation of previously efficient uterine activity • maternal tachycardia, hypotension or shock • loss of station of the presenting part

In this situation, resuscitate mother as necessary and deliver by caesarean section immediately. Postnatal review:

• Postnatal review should include discussion regarding circumstances relating to the delivery and plan for future birth (Appendix 2)

• Complete the information form and give the top copy to the patient to keep.

• Ensure that the patient understands she needs to hand it to the Obstetric team when she books for antenatal care in the next pregnancy.


5. Monitoring, Evaluation & Review Adherence to this policy will be audited at least once in every three year period. The results of the audit will be considered by the Women’s Quality Forum. If deficiencies in care are identified the Women’s Quality Forum will agree an action plan to improve care and be responsible for monitoring the implementation of the action plan.

6. References Royal College of Obstetricians and Gynaecologists. (2007). Birth after Previous Caesarean Section. London: RCOG. Available at: www.rcog.org.uk


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http://www.rcog.org.uk/

APPENDIX 1 CHECKLIST FOR DISCUSSION AND DOCUMENTATION IN ALL WOMEN

WHO HAD ONE PREVIOUS CAESAREAN SECTION Complete this form and file in the Back-up notes AT BOOKING

All women who have had a previous LSCS should be seen by Middle Grade or Consultant

Addressograph

Discussion on the mode of delivery – The plan should include the following- (TICK AS APPROPRIATE)

• Should be done at booking visit. • See at 36 weeks only if undecided regarding mode of delivery at booking

visit • Opts for elective LSCS • Opts for VBAC • Plan for the place of labour- CDS • Brief management plan for labour –

o IV access o Group and save o continuous EFM

• Plan for labour should this commence before 37 weeks-

Prev. 1 LSCS opting for elective LSCS and in active labour before 37 weeks: • Wishes to proceed with VBAC • Wishes to have LSCS

• Plan for labour at >/= 37 weeks- Prev. 1 LSCS opting for elective LSCS and in active labour after 37 weeks:

• Wishes to proceed with VBAC • Wishes to have LSCS

• Document that plan for labour discussed with the consultant obstetrician If Consultant not available in clinic, notes left for review by Consultant

Sign………………… Print……………………… Grade………………….. Date……………………….


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APPENDIX 2

Patient Information following Caesarean Section

Patient’s Addressogram

Reason for Caesarean Section Previous caesarean section Slower than expected progress in labour (Cervix dilated to ………………cm) Concerns about baby’s heart rate tracing/adequacy of oxygen to baby Bleeding due to premature separation of the after-birth/low-lying afterbirth Low-lying afterbirth Baby discovered to be breech in labour Unsuccessful attempt to deliver baby with forceps or vacuum (At full dilatation) Premature Labour Delivery of second twin Other ………………………………………………………………………………………… Type of incision on womb

classical low vertical low transverse Management of vaginal birth after caesarean (VBAC) 1-2-12

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Advice on mode of delivery in next pregnancy Vaginal birth after caesarean section (Provide Leaflet) Planned Caesarean Section (provide leaflet) Postnatal Check-up in 6weeks GP Name/Signature/Designation……………………………………………………… ………………………………………………………………………….. Date……………………………………….



7. Equality Impact Assessment Equality Impact Assessment Initial Screening Form

Title of Policy

Guideline for management of vaginal birth after caesarean (VBAC)

Directorate/Division (Department/Ward):

Maternity Service, Family Care Division

This policy for decision is therefore subject to an Equality Impact Assessment (EIA). The following questions have been completed to ensure that this policy does not discriminate against any particular equality target group. Details of the outcome of the EIA have also been included into the main body of the policy.

1. Describe in summary the aims, objectives and purpose of the policy,

including desired outcomes.

This guideline aims to provide evidence based and equitable management for pregnant women who have had a previous caesarean birth.

2. Who is intended to benefit from the policy and in what way?

Staff, pregnant women

3. Who are the main stakeholders in relation to the policy?

Staff, pregnant women

4. With regards to: Equality Target Groups

Is there any potential for adverse impact?

Could this lead to adverse impact and if so that?

Can this adverse impact be justified on the grounds of promoting equality of opportunity for one group, or for any other reason?

Please detail what measures or changes you have or will put in place to remedy any identified adverse impact.

Age

no

Disability

no

Gender

n/a

Race/Ethnicity

no


Religion or belief

no

Sexual orientation

n/a

Caring status

no

Human Rights Act

no



Social Deprivation

no

Cross-cutting issues

no

Please provide suitable evidence, such as the results of consultation, service take-up, service monitoring, surveys, stakeholder comments and complaints where appropriate. For audit trail purposes all consultation, if any has been undertaken, must be added to the Corporate Consultation Database. Please contact the Master Document Controller to facilitate this.

5. Are there any gaps in your evidence or conclusions that make it difficult for you to quantify the potential adverse impact?

no

6. If so, please explain how you will explore the policy in greater depth. You

may wish to consider undertaking secondary data analysis, further consultation or research or investigating best practice. Please contact the Equality and Diversity Manager on ext. 5825 if you want further advice.

If you have undertaken consultation as part of the policy, has the research been uploaded onto the Corporate Consultation Database? Yes If you are planning to undertake consultation or research as a result of this EIA, please submit a copy of this form to the Master Document Controller. The EIA form and policy has been checked and countersigned by the appropriate Chair of the authorising body as described in the Document Control Policy.



MATERNITY AND WOMEN’S HEALTH

8. Consultation List

Consultation should be sought from the following as a minimum: Divisional Nurse Susan Holland All Consultants – Obstetricians/Gynaecologists Women’s Quality Forum members Supervisors of Midwives Library Services Manager Jean Williams

Please feel free to circulate more widely within your teams as appropriate

Consultation Period - One month

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