2015 45 Birth After Previous Caesarean Flashcards
Which women are best suited for a VBAC?
- Majority!
- Singleton
- Cephalic
- 37/40+
- Single previous CS
What are the contraindications to VBAC?
- Previous uterine rupture
- Classical Caesarean scar (caution with T, J, low vertical & significant extensions)
- Absolute contraindications to vaginal birth eg placenta praevia
Can women with 2 or more Caesareans be offered VBAC?
Sometimes
With senior obstetric consultation
Individualised counselling
What are important features of antenatal VBAC counselling?
- Document final decision in advance of delivery date, latest 36/40
- Additional plan in case of spontaneous labour
- Consider VBAC checklist
- Patient information leaflet
What is the risk of uterine rupture in a) VBAC, b) unscarred uterus
a) 1:200
b) 2:10,000
Which risks are increased in VBAC compared to ERCS?
- Uterine rupture
- Greater adverse outcomes in EmCS after trial of VBAC
- HIE
- Perinatal death
Which risks are increased in ERCS compared to VBAC?
- Placenta praevia & accreta
- Pelvic adhesions
- Neonatal respiratory morbidity
How does IOL impact on the risk of a) uterine rupture b) EmCS, in VBAC?
a) 2-3x
b) 1.5x
What factors should be discussed with a senior obstetrician when considering IOL in VBAC?
- Decision to induce or augment
- Proposed method of induction
- Time intervals for serial VE
- Parameters of progress
In what special circumstances is there a lack of data about safety & efficacy of VBAC?
- Post-datex
- Twins
- Fetal macrosomia
- Antepartum stillbirth
- Maternal age over 40
How does preterm birth affect risks for VBAC?
- Similar success rates
- Lower risk of uterine rupture
Which types of uterine surgery are considered to have similar risks to VBAC?
- Myomectomy, lap or open
- Hysteroscopic resection of uterine septum
What are the risks of placenta praevia for different numbers of previous Caesareans?
1: 1% (0.6)
2: 1.7% (1.6%)
3: 2.8% (3.3%)
What are the risks of placenta accreta in women with placenta pravia & different numbers of previous Caesareans?
1: 11-14%
2: 23-40%
5+: 67%
What are the risks of requiring hysterectomy in a) VBAC for 1 previous CS b) VBAC with 2 previous CS?
a) 19 in 10,000
b) 56 in 10,000
Which risks are increased for VBAC with 2 vs 1 previous CS?
- Uterine rupture
- Hysterectomy
- Transfusion
What factors I crease the risk of uterine rupture in VBAC?
- Inter-delivery interval < 12 months
- Post-dates
- Maternal age > 40
- Obesity
- Lower prelabour Bishop score
- Macrosomia
- Decreased lower segment myometrial thickness on US
What % of women scheduled for ERCS go into labour before 39/40?
10%
What are the maternal outcomes for planned VBAC?
- Success 72-75%
- Shorter hospital stay & recovery if successful
- Uterine rupture 0.5%
- Increased likelihood future vaginal birth
- OASI 5%
- Instrumental 39%
- Maternal death 4 in 100,000
What are the maternal outcomes for ERCS?
- Planned delivery date
- Uterine rupture < 0.02%
- Longer recovery
- Reduction POP & urinay incontinence
- Option of sterilisation with advanced planning
- Future pregnancies: likely CS, increased placenta praevia & accreta, adhesions
- Maternal death 13 in 100,000
What is the maternal death rate for a) planned VBAC, b) ERCS?
a) 4 in 100,000
b) 13 in 100,000
What are the infant outcomes for planned VBAC?
- Transient respiratory morbidity less, 2-3%
- Antepartum stillbirth 1:1000, similar to spontaneous
- HIE increased, 8:10,000
- Perinatal death increased, 4:10,000
What are the infant outcomes for ERCS?
- Transient respiratory morbidity increased, 4-5%
- Reduction in HIE & perinatal death, < 1:10,000
What are the rates of successful VBAC in different situations?
- Overall 72-75%
- Previous vaginal birth 85-90%
- Reason, Fetal malpresentation 84%
- Reason, Fetal distress 73%
- Reason, Unsuccessful instrumental 61%
