VBAC Flashcards
Name the points of importance in antenatal counselling.
· Suitability for TOLAC and the rationale informing the decision has been discussed.
· Information about available birth options has been provided
· Information regarding the risks and benefits of each birth option has been provided
· A balanced discussion of the uncertainties has occurred
· Decision aids /other information have been provided
· Decision regarding preferred mode of birth has been agreed
· Woman has acknowledged the discussion about birth options and consent has been
obtained by GP Obstetrician or specialist Obstetrician
· Check list of counselling provided has been initialled appropriately by the carer, and kept in
the patient medical record file.
· Information on the recommendation in labour management at AHS for TOLAC has been
given and signed by the woman and her carer, and kept in the hand held record (HHR).
· The woman has the right to change her mind, and if she does, this should be documented in
the front of the Pregnancy hand held record, and a new consent form should be done
· External cephalic version is not contra-indicated in NBAC women
Name 5 important aspects to document when taking a history from a woman considering NBAC.
· Number of previous caesarean sections
· Indication for primary caesarean section
· Details of previous caesarean section (obtain copy of theatre notes if possible),including type of uterine incision
· Any other uterine surgery e.g. myomectomy, hysterotomy
· Time since caesarean section
· Complications during or after caesarean section
· Complications of any other pregnancies
· History of labour prior to having a caesarean section
· Other successful vaginal births
· Plurality of pregnancy
· Results of antenatal screening tests
· Capability to give consent
· Placental location
· Any other contraindications to vaginal birth
Name the 4 absolute contra indications to TOLAC.
· Previous classical ‘T’ or ‘J’ uterine incision
· Previous full thickness myomectomy
· Previous uterine rupture
· Contraindication to vaginal birth – e.g. Placenta Previa
What are the 4 risks of TOLAC?
- Uterine rupture 1:250
· In case of rupture, risk of hysterectomy 1:3, risk of fetal death 1:10
· Perinatal mortality (including stillbirth) 1:770 (risk is the same as that of a primip in labour)
· Usual risks associated with vaginal birth
What are the 5 risks of ERCS?
· Maternal death 1:7700 (vs 1:25000 in TOLAC)
· Hysterectomy 1:360 (vs 1:600 in TOLAC)
· Transfusion 1:80 (vs 1:110 for TOLAC)
· Ectopic pregnancy after caesarean relative risk 1.28 times higher than TOLAC (2)
· VTE relative risk doubles in ERCS
Name the 4 factors that increase the risk of uterine rupture. in TOLAC/VBAC
· Type and number of uterine incisions
· Induction of labour (without prostaglandins) doubles the risk
· Induction of labour with prostaglandins increases risk x 5
· Augmentation of labour
What methods can be used if induction of labour is required for TOLAC/NBAC?
- Balloon cather
- Artificial rupture of membranes.
- Syntocinon- is used as per the discretion of the consultant on call
Name 7 important considerations when monitoring a TOLAC/VBAC woman in labour.
- Contractions should be manually palpated.
- If CTG is non reassuring, while woman is on oxytocin, discontinue oxytocin
- If hyperstimulation is suspected stop the oxytocin and call Obs
- Maternal heart rate (MPR) should be recorded continuously on the CTG using a pulse
oximeter on the TOLAC woman with an oxytocin infusion. - In the TOLAC woman with no oxytocin infusion, maternal heart rate should be recorded
on the CTG using a pulse oximeter for a few minutes every half an hour. - Blood pressure 2 hourly
- Temperature 4 hourly
- Observation for vaginal blood loss
What are the 6 signs of an obstructed labour?
· Slow progress with descent of presenting part
· Slow progress with cervical dilatation
· Excessive caput and moulding, cervical oedema
· Maternal fever
· Fetal distress, including tachycardia
· Haematuria
When should a vaginal examination be performed in TOLAC/VBAC?
Performed by a midwife or GP Obstetrician on admission and once labour is established: at
least every 4 hours until 7 cm dilated then consider 2 hourly thereafter if spontaneous labour.
If augmented with an oxytocin infusion, more frequent VE may be required
Can labour be augmented for TOLAC/VBAC? If so how?
If indicated, the use of amniotomy and/or oxytocin to augment labour must be discussed with the woman and obstetrician prior to commencement.
Oxytocin augmentation is associated with an increased risk of uterine rupture
TOLAC/VBAC- When in 2nd stage of labour should an obstetrician be called?
Notify on call obstetrician when assessed /considered fully dilated
Name 7 signs of uterine rupture.
- Maternal tachycardia and hypotension
- Constant abdominal pain.
- PV bleeding
- Sudden change in presentation or application of the presenting part
- Haematuria
- Sudden change in CTG
- Sudden change in pattern of uterine contractions
