Birthrites: Healing After Caesarean.

Examples of VBAC Guidelines.

Guidelines and protocols for VBAC have similarities and differences. It may be helpful to compare them with those of your community.  Here is  a listing of a few.

Caesarean Guidelines

*Below is an example of accepted policies, re VBAC, within the average Australian Hospital.
I have highlighted my own comments/suggestions in regard to the rigidness of these current accepted policies.

VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) POLICY

For the majority of women with a previous Caesarean birth a trial of labour should be encouraged.

Less morbidity is encountered in women with successful VBAC compared with those having an elective repeat Caesarean birth. There are fewer blood transfusions, fewer postpartum infections and shorter hospital stays and have no increased perinatal mortality:(Obstetric and Gynaecology clinics of North America 26(2) 295-304 1999 Jun).

A woman with a prior Caesarean is at increased risk regardless of her mode of birth.

A failed VBAC (non-elective Caesarean section in labour) has a higher rate of maternal and neonatal morbidity than a successful VBAC or an elective repeat Caesarean.

The likelihood of uterine rupture with attempted VBAC is 0.5%. (0.2% uterine rupture, 1.1% asymptomatic dehiscence from case control studies). The risk of hysterectomy and perinatal death from uterine rupture are 0.05% and 0.07% respectively in hospitals equipped to provide rapid laparotomy. (Australian VBAC study) Major uterine rupture, before or during labour, after a classical Caesarean section is 5%.

ANTENATAL MANAGEMENT

An ultrasound scan should be performed to check placental localisation to look for abnormal placentation.

ABSOLUTE CONTRAINDICATIONS TO VBAC

1. Previous classical caesarean section

2. Previous inverted T uterine incision.

3. Previous uterine rupture.
I agree with these first three, but point out that even in this rare situation a minority of women may opt for VBAC, recognising the greater risk. Their right to autonomy must be respected, as well as a hospital's right to feel protected from litiginous clients. *Suggestion - in such a special case a more detailed consent form could be used - see the HBAC Consent Form on this website.

4. Previous cephalo-pelvic disproportion (CPD) with anticipation of CPD in the current pregnancy. In order to make this diagnosis; the fetus must have been occipito anterior (OA) position, with secondary arrest of progress, and with significant moulding and caput of the fetal head. Clinical pelvimetry examination should be used to confirm a small or abnormally shaped maternal pelvis, and the fetus must be anticipated to be comparable or larger in size than the previous baby.
CPD is not a reason to repeat Caesar. The following trial looks exactly at the group excluded by this policy.
Impey L. and O'Herlihy C. First delivery after caesarean delivery for strictly defined cephalopelvic disproportion. Obstet Gynecol 1998;92:799-803.
68% delivered vaginally in the next pregnancy, 47% with a larger baby. Of 15 women previously delivered by caesarean at full dilatation 11 (73%) delivered vaginally. In 19 patients pelvimetry had been performed. In 11 (63%) dimensions were judged to be abnormal. All underwent trial of labour and 6 (55% - including two with larger babies) delivered vaginally. - And this trial is a very important and well known VBAC trial.

Phelan et al. Vaginal birth after cesarean. AMJOG 1987;157:1510-5.
"Previous indication for cesarean birth bears only little relationship to the subsequent successful vaginal delivery".
75% of women with previous cesarean for CPD/failure to progress delivered vaginally.

*This study looks a group commonly called "CPD" . Jongen VHWM et al.
"Vaginal delivery after previous caesarean section for failure of the second stage of labour". BJOG 1998;105:1079-81.
82 (80%) of 103 women with previous delay in descent in second stage delivered vaginally, including 41 (75%) of 55 who had a history of failed instrumental delivery.

Where is the evidence that clinical pelvimetry is useful where there is evidence that radiological pelvimetry just increases Caesar rates and is a poor predictor of the outcome of labour? (Thubusi et al. BJOG 1993; 100:421-4).

The baby's weight is also not relevant.
Flamm BL and Goings JR. "Vaginal birth after caesarean section: Is suspected fetal macrosomia a contra-indication."
4000-4499 range, 139 of 240 patients (58%) delivered vaginally. Greater than 4500g, 43% delivered vaginally. Comparison with control group of 301 women with no previous uterine surgery and macrosomia, showed no significant difference in perinatal or maternal morbidity.

4. Lack of maternal cooperation.
*Suggestion - that cooperation is the wrong word as it has a sense of misbehaviour. It is important for a woman to take responsibility and be informed re both VBAC and caesarean birth.

Please note, lack of maternal agreement is also a good reason not to do a caesarean.

5. Development since the previous delivery of a strong indication for elective Caesarean section
?? - This is a very unspecific guideline, which makes if difficult to research the literature. This just comes across as a "getout" clause, and such a clause is not present in either the ACOG or SGOC guidelines.

RELATIVE CONTRAINDICATIONS TO VBAC

1. More than two previous Caesarean sections.
SCOG guidelines, which are above, state... "Labour and vaginal delivery in women with more than one previous transverse low segment incision is an acceptable option, although there are less data available."

ACOG guidelines, also above, state that… "a woman who has two, or more, previous c/section deliveries with lower transverse uterine incisions, who has no other contraindications, and who wishes to attempt vaginal birth, should not be discouraged from doing so".

2. Non cephalic presentation
I understand that this may alter once findings of the term breech trial are digested, in which VBAC women did participate, but at the moment limited evidence suggests VBAC breech birth is a reasonable option.

"Obstetric Myths vs Research Realities" by Henci Goer. (Pages 111 &endash; 112)
Primiparas, nonfrank breeches, and VBAC candidates should not be routinely excluded from vaginal birth. (Abstracts 1-3, 5, 41-43)

An alternative to elective c/section at 38weeks gestation, may be to wait until the due date to be sure the baby is not going to turn - some babies do (they've even been known to turn during labour, though this is not very likely).
Another alternative is ECV (turning the baby manually, externally. Done by the Obstetrician late in pregnancy).
There are also exercises to try - raising the pelvis above the head for a few minutes (talk to your caregiver about these positions before trying) or using sound, or light, to encourage the baby to turn. The mother plays the music, or places the light/torch (in a darkened room) on her belly next to the baby's head, then slowly (very, very slowly) moves it downwards towards where she wants her baby's head to be - in the perfect head-down position for birth. It may spike the baby's interest, and the baby may follow it's curiosity downwards... It has supposedly worked, and is worth a try.

3. Significant previous post Caesarean section sepsis.

Counselling with regards to the surgical and anaesthetic risks, increased thromboembolic disease and Respiratory Distress Syndrome in the neonate versus the risks of VBAC should be provided and carefully documented in the case notes.
There is a wonderful document, written by an Obstetrician by the name of Dr. Hill that would be a good 'handout' for VBAC women (it's address on the web is http://www.obgyn.net/women/articles/VBAC_dah.htm). It explains VBAC and c/section birth in simple language, listing the pros and cons of each method. Maybe a summarised version, with permission, or something similar would be valuable.

The decision to proceed with induction of labour in women with a previous Caesarean section should be discussed antenatally with the Senior Registrar/Consultant.

Induction of labour decreases the success rate of VBAC.
Women should be informed that it also affects the risks involved. All women undergoing induction/augmention should be made aware of the increased risks &endash; that it is no longer 0.5 &endash; 1% as quoted earlier.

Many women find it a really difficult time around the due date.
*Suggestion - that a support group, such as Birthrites: Healing After Caesarean Inc. can have a very positive role at this time, helping the doctors who would naturally be trying to avoid "social" induction.

INTRAPARTUM MANAGEMENT

Patients who have had a previous Caesarean section are excluded from the Family Birth Centre.
Patients are being denied the right to choose where they wish to birth. Their options are being limited in this way.

The patient should be advised to present to Delivery Suite early in labour.

Intravenous access should be established and blood taken for a group and hold serum or cross matching if appropriate.
A good question would be "Are there resident medical staff at your hospital, or do the midwives put in the IV lines? How long it would take to put in an IV line should an emergency occur?" It may only be a matter of a few minutes and the patient may be comfortable with this short delay. It's all about informed decision making. The pros and cons of an IV bung should be explained, and the psychological impact of the necessity for IV access (fear?) should be acknowledged.

The patient should be fasted.
Most caesars are spinals. Most women don't want to eat in labour so proscriptive rules like this just damage the relationship between the women and carers.
*Suggestion - that with an expected VBAC rate of 80% that it is probably little different to the Caesar rate for primips (say 10%) so why have a different rule. It would be more acceptable to allow a "light diet only in early labour. Fluids only in established labour". This would include lollies!

Labour should be monitored using the partogram and any abnormalities should be notified to the registrar, who should perform an assessment.
I think it is advisable for each registrar on the shift to try to meet the woman early in labour, before any exams are needed, to get to know her views, to read and discuss her birthplan, talk about her past experience, to see the woman not the labour. This is the way to get better outcomes for both 'sides'.

Continuous fetal heart rate monitoring is mandatory.
Please note the SGOC guidelines (above) state... "One of the most consistent early signs of scar dehiscence and/or rupture is an abnormal fetal heart rate pat-tern. Thus, in cases of induction and/or augmentation, continuous electronic fetal heart rate monitoring is advised. Intermittent fetal heart monitoring is to be reserved for cases in which neither induction nor aug-mentation with oxytocin is performed.

There are other reputable bodies that are comfortable with this view in non-induced/augmented labours. Perhaps auscultation with the doptone every 15 minutes in first stage and after each contraction in second stage might be a reasonable compromise. This is what they suggested for the breech trial - and many suggest continuous monitoring for breeches.

There is no contraindication to epidural analgesia

Any delay in latent/active phase of labour or fetal heart rate abnormalities should be discussed with the consultant Obstetrician on call for Delivery Suite with a view to Caesarean section.

*Abnormalities in the fetal heart trace, such as variable or late decelerations, prolonged fetal bradycardia, may warrant Emergency Caesarean section without recourse to fetal scalp pH measurement, as they may be the first signs of scar rupture/dehiscence.

Should oxytocin be required, the available evidence suggests that its use is associated with a reduced success of vaginal birth and a doubling of scar rupture/dehiscence. However, oxytocin may be used with caution in women with a previous Caesarean section, following discussion with the consultant Obstetrician on call for Delivery Suite. :

Induction of labour with amniotomy/oxytocin and/or Foley catheter may be performed.

Prostaglandins are not licensed in Australia for use in-patients with a uterine scar.

Be vigilant for the symptoms and signs of scar rupture, which may include:

  • Suprapubic tenderness and/or severe constant abdominal pain which continues between contractions
  • Maternal tachycardia
  • Vaginal bleeding
  • Fetal tachycardia or fetal heart decelerations
  • No progress in labour
  • Cessation of contractions

What about a trial/study on the feelings of control that a woman attempting a VBAC may require? A comparison between VBAC, elective caesarean and emergency caesarean in labour, the reactions of the women and the feelings of control that they were able to maintain in each situation. Even just a questionaire &endash; our group could definitely help with that - See the Birth Survey on this website.

There are many psychological ramifications of a caesarean birth. These continue on, if this mode of delivery was unexpected and considered undesirable by the mother, during the next pregnancy and birth. The loss of control, and the fear associated with an earlier birth experience, may result in the need to maintain control the next time. The amount of technology involved and the sterile atmosphere may cause a need for a 'natural' labour and a reduction in unnecessary interventions. When women choose a VBAC birth, they tend to be making an extremely informed choice in doing so, this needs to be acknowledged and respected.