Vaginal Birth after Caesarean

section
(VBAC)
Recommendations = Women with a previous C-section have the
choice to undertake VBAC or elective C-section
Commonly used acronyms
VBAC = Vaginal birth after C-section
TOL = Trial of labour
TOVBAC = Trial of vaginal birth after C-section
ERCS = Elective repeat casarean section
For trial of labour after C-section about 60-80% will have a
successful vaginal delivery; otherwise will need a repeat Csection
Additional measures for trial of labour for VBAC:
Placement of IV line, oral intake of clear fluids and preparation
of blood products for TOL
Intense surveillance for early signs of uterine rupture
(abdominal pain, PV bleed, cessation of contractions,
tachycardia, shock, fetal compromise)
Continuous CTG monitoring of fetus
Augmentation and induction whilst not contraindicated should
be used with caution (no prostin)
Factors which influence success
Previous Hx of successful vaginal birth (4x more likely to
succeed for VBAC)
Previous reason for C-section
Size of baby
Common contraindications
Absolute: Previous classical/upper-segment C-section,
previous uterine rupture, inadequate facilities for emergency
C-section
>1 previous C-sections
C-section <18 months
Large baby (>4kg)
Multiple gestation
Non-vertex presentation
Maternal morbid obesity

Benefits of vaginal birth

Shorter recovery period
Lower rate of maternal complications esp. post-partum fever,
wound infection, VTE, iatrogenic error
Less likely for fetus to develop respiratory problems
(particularly transient tachypnoea of newborn)
Complications
4% Uterine dehiscence (partial rupture)
1 in 200 Uterine rupture
?Minor increase in perinatal mortality for mother and child
(independent of uterine rupture)
Practice OSCE scenario:
Shelly is a 32 year-old lady who is G2P1. Her previous delivery was
an elective caesarean section due to breech presentation. Other
than the procedure there were no perinatal complications.
She has come into the antenatal clinic and is 24 weeks pregnancy.
She is wondering about the possibility of a vaginal birth. Please
counsel Shelley about having a trial of labour and a VBAC.
References
http://www.ranzcog.edu.au/doc/planned-vbac.html
Obstetrics and Gynaecology by Ten Teachers