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vbac (vaginal birth after caesarean): intrapartum management

VBAC (Vaginal Birth after Caesarean): Intrapartum Management CPG

Definition of terms

Intrapartum Management

On admission

Ongoing management

First Stage

Second Stage

Third Stage

Notes

References

1. Purpose

According to the Consultative Council on Obstetric and Paediatric Mortality and Morbidity1 in Victoria the caesarean section rate has been steadily increasing in public hospitals statewide from 21% in 2000 to 27% in 2005.

The most common indications for caesarean section are previous caesarean section, dystocia, malpresentation and non-reassuring fetal status2.

Vaginal birth after caesarean section (VBAC) should be considered as an option for all women who present for prenatal care with a history of previous caesarean birth. Where contraindications exist a repeat caesarean section will be advised, but in the majority of cases successful vaginal birth can be achieved safely for both mother and baby2.

The success rate of VBAC ranges from 50% to 85%(3). Predictors of successful VBAC include:

Non-recurring indication of caesarean section (eg malpresentation)2

Pregnancy induced hypertension2

Previous vaginal birth2

Institutions in which success rates are high2

Onset of labour is spontaneous

It is essential women make an informed choice regarding whether to attempt a vaginal birth or whether to plan another caesarean section. Therefore, these guidelines recommend that obstetricians and women discuss the risks and benefits of VBAC (reinforced by the provision of appropriate literature) to plan the birth.

2. Definition of terms

Vaginal Birth After Caesarean Section (VBAC)

Active first stage of labour

Painful, regular contractions
Descent of the presenting part
Cervix is fully effaced, dilatation is 3 cm4 and progressively dilating, and/or

With or without spontaneous rupture of membranes.

OR

Onset of labour

Painful, regular contractions
Effacement and/or dilatation of the cervix, and/or
With or without rupture of membranes (assess presence of vaginal loss for quantity, colour).2

3. Intrapartum Management

3.1 On admission

Inform registrar on admission to birth suite of all women who have a uterine scar.

The registrar must refer to the Women's VBAC Antenatal Assessment form to review and revise the management plan prepared antenatally in consultation with the woman.

Notify anaesthetist and theatre of any patient for planned VBAC in birth suites and in labour.2

IV access with 16G cannula from onset of labour.

Blood to be taken for:

Group and save
Hb

3.2 Ongoing management

ARM to be performed once the cervix is:

3cm dilated, and
effaced, and
applied to the presenting part.

Continuous Electronic Fetal Monitoring throughout the labour.2,4

Aim to deliver within 12 hours of onset of active labour.

In suspected uterine dehiscence activate a Code Green.2

3.3 First Stage:

Vaginal Examination by JMO / registrar every 4 hrs until 7cm dilated, and 2-hourly thereafter. JMO to notify registrar of findings at each assessment.

Progress: anticipate 1 cm dilatation / hour (after achieving 3cm). Discuss progress with on-call obstetric consultant if less.

In general, oxytocin augmentation is not contraindicated in women undergoing a VBAC. Plans to augment must be discussed with the on call obstetric consultant prior to commencement of a syntocinon infusion.2

Epidural may be used as indicated.

3.4 Second Stage:

Notify registrar when patient assessed / considered to be fully dilated.

Duration should not exceed 2 hours: 1 hour to allow for passive descent, but no more than 1 hour of active pushing (or 30 minutes if the woman has had a prior vaginal delivery).

The option of any mid-cavity assisted vaginal delivery MUST be discussed with the consultant.

No mid-cavity assisted delivery to be performed without the consultant being present, and then to be performed in the operating theatre.

3.5 Third Stage

Active management. Refer to CPG: Labour: Third Stage Management

Digital examination of the scar is not required.

4. Notes

Refer to the Women's CPG: VBAC (Vaginal Birth After Caesarean Section): Antenatal Management

If prelabour ROM, management as per appropriate CPG: Rupture of Membranes: Premature at Term.

5. References

1. The Consultative Council on Obstetric and Paediatric Mortality and Morbidity, Hospital Profile of Perinatal Data, Royal Women's Hospital (2005).

2. Society of Obstetricians and Gynaecologists of Canada (SOGC) Clinical Practice Guidelines: Guidelines for Vaginal Birth After Previous Caesarean Birth (2005).

3. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. The Cochrane Database of Systematic Reviews (2004), Issue 4.

4. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Clinical Guidelines: Intrapartum Fetal Surveillance (2002).

Evidence table

VBAC: Intrapartum management evidence table

(pdf 11kb)

2 August 2007

Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.

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