VBAC Flashcards
What is the recommended schedule of antenatal care for pregnant women with previous caesarean delivery?
Implement VBAC vs ERCS checklist or clinical care pathway to facilitate best practice in - antenatal counselling, - shared decision making and - documentation.
Which women are best suited to have a planned VBAC?
majority:
- singleton,
- cephalic,
- at 37+0 or beyond
- previous 1 LSCS,
- with or without previous vaginal birth.
What are the contraindications to VBAC?
- previous uterine rupture or
- classical CS scar
- other absolute contraindications to vaginal birth that apply irrespective of presence or absence of scar (e.g. major placenta praevia).
- complicated uterine scars, caution & decisions on
- case-by-case basis
- by senior obstetrician
- with access to details of previous surgery.
Can women with two or more prior caesareans be offered planned VBAC?
- two or more prior LSCS may be offered VBAC
after counselling by senior obstetrician. - include risk of uterine rupture &
- maternal morbidity, and
- individual likelihood of successful VBAC (e.g. given a history of prior vaginal delivery).
- Labour in centre with suitable expertise and recourse to immediate surgical delivery.
What factors are associated with an increased risk of uterine rupture in women undergoing VBAC?
- individualised assessment of suitability for VBAC should be made in women with factors that increase risk of uterine rupture.
What are the overall aims of antenatal counselling of previous 1 LSCS?
- antenatal counselling of women with a previous LSCS documented in notes.
- final decision for mode of birth agreed upon by woman and Doctor, before EDD/planned CS.
- date for ERCS: plan for if labour starting before scheduled date documented.
- routine VBAC checklists during antenatal counselling :ensure informed consent and shared decision making in VBAC.
- patient information leaflet: with consultation.
What are the risks and benefits of planned VBAC versus ERCS from 39+0 weeks of gestation?
1- successful VBAC has fewest complications
2- chance of VBAC success or failure: important consideration when choosing the mode of delivery.
3- greatest risk of adverse outcome occurs in a trial of VBAC resulting in emergency CS.
4- planned VBAC 1 in 200 (0.5%) risk of uterine rupture.
5- absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labour.
ERCS
1- small increased risk of placenta praevia and/or accreta 2- pelvic adhesions complicate future Abdominopelvic surgery.
3- risk of perinatal death extremely low,
4- small increase in neonatal respiratory morbidity
5- ERCS <39+0 weeks:. respiratory morbidity reduced with preoperative antenatal corticosteroids.
What is the likelihood of VBAC success?
Women should be informed that the success rate of planned VBAC is 72–75%.
What factors determine the individualised likelihood of VBAC success?
- previous vaginal delivery, particularly previous VBAC, is single best predictor of successful VBAC and is associated with planned VBAC success rate of 85–90%.
- Previous vaginal delivery is also independently associated with a reduced risk of uterine rupture.
What delivery setting is appropriate for conducting planned VBAC?
- suitably staffed and equipped delivery suite with
- continuous intrapartum care and monitoring with
- available for immediate CS and
- advanced neonatal resuscitation.
- unplanned labour and previous LSCS: discussion with experienced obstetrician to determine feasibility of VBAC.
- Epidural analgesia not contraindicated in planned VBAC, ( increasing requirement for pain relief, possibility of impending uterine rupture).
- continuous electronic fetal monitoring for duration of planned VBAC, commencing at onset of regular uterine contractions
How should women with a previous caesarean birth be advised in relation to induction or augmentation
of labour?
induced and/or augmented labour VS spontaneous
- two- to three-fold increased risk of uterine rupture and
- 1.5-fold increased risk of CS in
- senior obstetrician discuss:
1- decision to induce labour,
2- proposed method of induction,
3- decision to augment labour with oxytocin,
4- time intervals for serial vaginal examination
5- selected parameters of progress that necessitate discontinuing VBAC. - IOL by mechanical methods (amniotomy or Foley) with lower risk of scar rupture compared with induction using prostaglandins.
What elements are involved in the perioperative, intraoperative and postoperative care for ERCS?
- ERCS after 39+0 weeks.
- Antibiotics before skin incision in ERCS.
- receive thromboprophylaxis according to RCOG
- Early recognition of placenta praevia, MDT & informed consent important considerations in MX in placenta praevia and previous caesarean delivery.
How should women in special circumstances be cared for?
uncertainty about safety and efficacy of planned VBAC in pregnancies complicated by 1- post-dates, 2- twin gestation, 3- fetal macrosomia, 4- antepartum stillbirth or 5- maternal age of 40 years or more. - cautious if VBAC - planned preterm VBAC has similar success rates to planned term VBAC but with a lower risk of uterine rupture.
