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ImbibeMe / ImbibeMed / MRCOG Part 2 / Module 4 – Labour and Delivery / ‘Birth after Previous Caesarean Birth’ for MRCOG.
| Planned VBAC - Best suited | Further consideration/discussion | Planned Elective Caesarean section (vaginal birth contraindicated) |
|---|---|---|
|
Single previous caesarean section In a singleton pregnancy with cephalic presentation at 37 weeks' or beyond, with or without previous vaginal delivery. |
Complicated uterine scars |
Previous uterine rupture |
|
|
2 or more prior LSCS |
Previous classical caesarean section |
|
|
|
Other absolute indications to vaginal birth (e.g. major placenta praevia) |
| Criteria | Planned VBAC | Planned Elective Caesarean section |
|---|---|---|
|
Uterine scar rupture |
0.5% risk (1 in 200) |
< 0.02% risk |
|
Maternal death rate |
4/100 000 |
13/100 000 |
|
Blood transfusion |
2% (2 per 100) |
1% (1 per 100) |
|
Endometritis |
No significant difference in risk |
|
|
Transient respiratory morbidity |
2 - 3% |
4 - 5% (6% if delivery at 38 weeks instead of 39 weeks). |
|
Hypoxic ischaemic encephalopathy |
8 per 10 000 |
< 1 per 10 000 |
|
Perinatal death rate |
4 per 10 000 |
< 1 per 10 000 |
|
Antepartum stillbirth (while awaiting spontaneous labour beyond 39+0 weeks) |
10 per 10 000 (1.5 to 2 fold higher than women without previous LSCS) |
-- |
|
Anal sphincter injury |
5% (birth weight is the strongest predictor of this). Rate of instrumental deliveries - increased upto 39%. |
-- |
|
Other benefits |
72 - 75 % chance of successful VBAC, if successful, shorter hospital stay and recovery. |
Less risk of - pelvic organ prolapse and urinary incontinence. Option for sterilisation. |
|
Future pregnancies |
Increased chances of future vaginal birth |
Increased risk of placenta praevia/accreta and adhesions. |
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Success rate of planned VBAC is 72 – 75%.
Previous vaginal delivery, particularly previous VBAC, is the single best predictor of successful VBAC. It is associated with a planned VBAC success rate of 85 – 90%.
Previous vaginal delivery is also independently associated with a reduced risk of uterine rupture.
Greatest risk of adverse outcome occurs in a trial of VBAC resulting in emergency caesarean delivery.
In induced and/or augmented labour (compared with spontaneous VBAC labour), there is 2 – 3 fold increased risk of uterine rupture and 1.5 fold increased risk of caesarean delivery.
Induction of labour using mechanical methods (amniotomy or Foley catheter) is associated with a lower risk of scar rupture, compared with induction using prostaglandins.
Higher VBAC success rate with :-
Planned VBAC should be conducted with continuous intrapartum care and monitoring.
Continuous electronic fetal monitoring for the duration of planned VBAC, commencing at the onset of regular uterine contractions.
Women with unplanned labour and a history of previous caesarean delivery should have a discussion with an experienced obstetrician to determine feasibility of VBAC.
Epidural analgesia – NOT contraindicated in a planned VBAC.
Increasing requirement for pain relief should raise awareness of the possibility of an impending uterine rupture.
ERCS should be conducted after 39+0 weeks of gestation.
Antibiotics should be administered before making the skin incision in women undergoing ERCS.
All women undergoing ERCS should receive thromboprophylaxis.
Early recognition of placenta praevia.
Risk of placenta praevia in subsequent pregnancies with one, two or three or more previous caesarean deliveries experience a 1%, 1.7% or 2.8% risk respectively.
Risk of uterine rupture before labour with a previous classical incision on the uterus is 2%.
Uncertainty about safety and efficacy of planned VBAC in pregnancies complicated by :-
Planned preterm VBAC has similar success rates to planned term VBAC but with a lower risk of uterine rupture.
VBAC Score has been studied to predict the success of women attempting VBAC.
It consists of five features :-
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Success rate of planned VBAC is 72 – 75%.
Previous vaginal delivery, particularly previous VBAC, is the single best predictor of successful VBAC. It is associated with a planned VBAC success rate of 85 – 90%.
Rate of uterine scar rupture – 0.5% with planned VBAC and < 0.02% with elective caesarean section.
Risk of uterine rupture before labour with a previous classical incision on the uterus is 2%.
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