VBAC Guideline V5.0 GL930

Vaginal birth after caesarean
section (VBAC) guideline (GL930)

Approval
Approval Group Job Title, Chair of Committee Date
rd
Maternity & Children’s Services Chair, Maternity Clinical 3 November
Clinical Governance Committee Governance Committee 2017
Change History
Version Date Author, job title Reason
3.0 April 2014 Emma Maycock, Midwife Review of existing guideline to
reflect change of practice
3.1 November P Street (Consultant Pg 7 – Augmentation
2014 Obstetrician)
3.2 April 2015 C Harding (Clinical Lead Update of the auditable
Midwife D/S) standards on page 8
Updated VBAC counselling
checklist pg 11/12
4.0 Oct 2015 Jane Siddall (Consultant Reviewed against updated
Obstetrician) RCOG green top No 45
published 1/10/15
4.1 Mar 2017 C Harding (Consultant MW) App 2 – VBAC pathway updated
5.0 Oct 2017 J Bussey (VBAC specialist Reviewed – App 1 VBAC
MW) counselling checklist updated
C Harding (Consultant MW), P Pg 2, 3, 5 & 7 changes made to
Bose (Consultant reflect current practice.
Obstetrician),
Author: C Harding, J Bussey Date:

Job Title: Consultant Midwife, VBAC Specialist MW Review Dat
Policy Lead: Group Director Urgent Care Version:
Location: Policy hub/ Clinical/ Maternity / Intrapartum/ GL930
This document is valid only on date last printed
Maternity Guidelines – Vaginal birth after caesarean (VBAC) guideline (GL930) November 2017
Aim: To present the best available evidence to facilitate antenatal counselling in women
with one prior CS birth and to formulate intrapartum management.
Introduction
Increasing rates of primary caesarean section have increased the population with a history
of prior caesarean delivery. Women with previous CS may be offered either planned
Vaginal Birth after Caesarean Section (VBAC) or elective repeat caesarean section
(ERCS)
Although there are no randomised controlled trials comparing planned VBAC with planned
ERCS, VBAC remains a safe option and should be recommended to women with a prior
history of one uncomplicated lower segment transverse caesarean section in an otherwise
uncomplicated pregnancy at term¹.
Antenatal counselling
 Women with a prior history of one uncomplicated lower-segment transverse CS, in
an otherwise uncomplicated pregnancy at term, with no contraindications to vaginal
birth, should be referred to the midwife-led VBAC clinic to discuss the option of
planned VBAC.
 All of these women should be provided with a VBAC patient information leaflet at
her booking appointment with the community midwife. If the mother has not
received one, a copy should be given to her at the hospital appointment.
 There should be a review of the operative notes of the previous CS to identify the
indication, type of uterine incision, and any peri-operative complications that may
require referral to a consultant obstetrician to consider an elective caesarean
section.
 Women should be counselled about the maternal, perinatal and neonatal risks and
benefits of planned VBAC and ERCS when deciding the mode of delivery. The key
issues to include in the discussion are listed below.
 Women considering VBAC should be informed that, according to the Royal College
of Obstetricians and Gynaecologists, the overall chances of a successful planned
VBAC are 72-76%1. Currently, the average success rate at this hospital is
60%.(16/17 data)
 Previous vaginal birth, particularly previous VBAC, is the single best predictor for
successful VBAC and is associated with an approximately 85-90% planned VBAC
success rate1.
 Women planning VBAC will remain midwife-led antenatally, unless other
complications requiring obstetric input arise.
 Attendance at the VBAC class between 34 and 37 weeks should be recommended
Author: C Harding, J Bussey Date: November 2017

Job Title: Consultant Midwife, VBAC Specialist Midwife Review Date: November 2019
Policy Lead: Group Director Urgent Care Version: V5.0 ratified 3/11/17
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Location: Policy hub/ Clinical/ Maternity/ Intrapartum/ GL930
This document is valid only on date last printed Page 2 of 11
 Approaching 40 weeks, women planning VBAC should have appointment at the

VBAC clinic. This will include vaginal assessment and stretch and sweep, and a
discussion on mode of delivery post-dates. Suitable induction of labour methods
should be decided.
 The VBAC counselling checklist (appendix 1) should be used to document all
consultations and this should be filed in the woman’s hospital notes.
Benefits and harms of VBAC versus ERCS

The evidence for all outcomes is predominantly from cohort studies and should be
interpreted with caution2.
The complication most usually cited by women is:
Uterine rupture
The immediate risk that women planning a VBAC should be made aware of is uterine
rupture. Uterine rupture has an estimated incidence of 0.2 per 1000 maternities overall,
and can occur during pregnancy or labour.
The incidence in women undergoing planned VBAC is 1 in 500 ( or 99.8% safe)
maternities, while in women having an ERCS this risk is reduced to 1 in 3000 (or 99.97%
safe) maternities.
Although a rare outcome, uterine rupture is associated with significant maternal and
perinatal morbidity and perinatal mortality. The risk of uterine rupture may be greater
among those who have had two or more previous caesarean deliveries, or those who have
had a caesarean delivery less than 12 months previously, or in those whose labour is
being induced4. Uterine rupture may also occur after gynaecological surgery such as
myomectomy1
There are consequences to repeat LSCS which must be discussed when considering birth
options:
Future pregnancies
Women should be informed that ERCS increases the risk of serious complications in future
pregnancies. The following risks significantly increase with increasing number of repeated
caesarean deliveries: placenta praevia( it happens to 1 in 100 after 1 LSCS, 2 in 100 after
two and about 3 in 100 after three) , placenta accreta( will occur in1 in 7 to 1in 10 women
with a placenta praevia); injury to bladder, bowel or ureter; ileus; the need for
postoperative ventilation; intensive care unit admission; hysterectomy; blood transfusion
requiring four or more units and the duration of operative time and hospital stay1.
All women should be aware of:

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Minor or transient complications of Caesarean birth
Blood transfusion and Infection

The rate of blood transfusion is lower in ERCS than in VBAC (0.9 fewer per 1000). There
is no statistically significant difference between the rates of infection among ERCS or
VBAC groups5.
Respiratory morbidity in the neonate

Compared with neonates delivered vaginally or by emergency caesarean sections, those
delivered by elective caesarean section around term have an increased risk of overall
(transitory tachypnoea of the newborn, respiratory distress syndrome, persistent
pulmonary hypertension of the newborn) and serious respiratory morbidity (oxygen therapy
for two or more days, nasal continuous positive airway pressure, or need for mechanical
ventilation)6.
Emergency CS
Women should be made aware that there is a risk of unplanned CS for both ERCS and
VBAC. 10% of women scheduled for ERCS go into labour before the 39 th week. Risk
factors for unsuccessful VBAC are: induced labour, no previous vaginal birth, body mass
index greater than 30 and previous caesarean for dystocia7.
Serious complications
Antepartum stillbirth
An extra 1in 1000 mothers with a prior LSCS will experience a stillbirth after 39 weeks
compared to mothers with no history of prior LSCs or stillbirth. The reasons are not known.
However, earlier delivery by ERCS or induction of labour is not recommended.
Hypoxic ischaemic encephalopathy in the neonate

The incidence of intrapartum hypoxic ischemic encephalopathy (HIE) at term is
significantly greater in planned VBAC (7.8/10,000) compared with ERCS (zero rate).
However, over half of these cases were due to uterine rupture.1 This complication is very
rare, and no different to rates in mothers who labour without a prior Caesarean delivery.
Hysterectomy
There is no evidence of higher risk of hysterectomy in the VBAC group compared to ERCS
group.
Hospital stay
The mean length of hospital stay is longer among women with ERCS when compared with
women who have a VBAC5. However, mothers who have an uncomplicated ERCS will
normally stay in hospital for only 1-2 nights.

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Contraindications to VBAC1
 Extended uterine incision at index LSCS (e.g. T or J shaped incisions)
 Previous uterine rupture
 Previous high vertical classical CS
 Three or more previous CS deliveries
 Previous myomectomy or prior complex uterine surgery
Women with a short interval between initial CS and VBAC and those known to have
fetal macrosomia should not be offered induction of labour unless agreed with a
consultant obstetrician
Planned VBAC in special circumstances

All mothers should be advised to labour in a fully equipped hospital based setting.
 Twins
 Women with a prior history of two uncomplicated low transverse CS in an
otherwise uncomplicated pregnancy at term, with no contraindication for vaginal
birth, who have been fully informed by a consultant may be considered suitable for
planned VBAC.
 Women with previous uterine incision other than uncomplicated low transverse
CS incision, who wish to consider VBAC, should be assessed by a consultant
obstetrician with full access to the details of the previous surgery. Provided the
woman has been fully informed by a consultant obstetrician of these increased risks
and a comprehensive individualised risk analysis has been undertaken of the
indication for and the nature of previous CS then planned VBAC may be supported.
 Women who are preterm and considering VBAC should be informed that planned
preterm VBAC has similar success rates to planned VBAC at term, but with a lower
risk of uterine rupture.
Intrapartum care during planned VBAC

 In the latent phase of labour an individual assessment should be made to support
the recommendation for remaining or returning home by the midwife. Routine VBAC
labour assessments are to be carried out on Rushey MLU (midwifery-led unit). This should
include a 20 minute CTG monitoring. If maternal and fetal observations are normal and
contractions remain irregular, a woman planning VBAC, who is coping well, can
remain at home Those who do not wish to go home may remain on MLU during the latent
phase of labour, subject to capacity. An obstetric review is necessary on second or
subsequent admissions if still in latent phase.
 Prolonged rupture of membranes (PROM) in women planning VBAC should be
managed the same as women with no history of prior Caesarean section.
Consultant Obstetrician authorisation is required if augmentation is necessary.
 Women should be admitted to the delivery suite once in established labour.
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 An intravenous access assessment (to determine if cannulation would be difficult in

an emergency), should be made on admission and documented in the records. FBC
and G&S must be taken and sent for all planned VBAC’s.
 Intravenous access should be secured as soon as maternal and/or fetal
observations deviate from normal (or sooner if cannulation is predicted to be
difficult).
 Ensure Ranitidine 150mg is prescribed and administered orally every 6-8 hours.
 Continuous intrapartum maternal and fetal monitoring is advised to facilitate the
diagnosis of uterine scar rupture.
 Women should be advised to have Continuous Electronic Fetal Monitoring (CEFM)
following the onset of regular uterine contractions for the duration of labour.
Telemetry should be used to facilitate mobility.
 If using telemetry, women may be encouraged to use the birthing pool on delivery
suite for the first stage of labour provided that labour progresses normally with
confirmed fetal and maternal wellbeing.
 All other pain relief options are suitable during planned VBAC.
 Care in labour should also focus on encouraging women to remain mobile,
changing position as much as possible, and emptying of bladder every 2-3 hours.
Encourage women to remain hydrated with the use of oral H20 and still isotonic
drinks.
 The midwife should review the progress of labour with abdominal palpation and
vaginal examination every 4 hours. The expected rate of progress is 1cm dilatation
an hour.
 Lack of progress should be discussed with the Registrar and the Consultant
Obstetrician on call.
 High suspicion of the potential risk of uterine scar rupture (see below), followed by
expeditious laparotomy and resuscitation is essential to reduce the associated
morbidity and mortality in mother and infant (please see Ruptured Uterus guideline).
Signs and symptoms of scar rupture (one or more may be present):

 Severe abdominal pain persisting between contractions, with or without an epidural
in situ
 Chest pain or shoulder tip pain or sudden onset shortness of breath (referred
diaphragmatic pain)
 Acute onset scar tenderness
 Abnormal vaginal bleeding or haematuria
 Abnormal CTG
 Cessation of previously efficient uterine activity
 Maternal tachycardia, hypotension or shock
 Rising station of the presenting part/(may rise out of the pelvis)
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Induction and Augmentation

Women should be informed of the 2-3 fold increased risk of uterine rupture and around 1.5
fold increased risk of CS in induced and or augmented labour compared with spontaneous
onset of labour1, 5
Induction with prostaglandins
Cervical ripening with prostaglandins is probably safe in selected cases but numbers
studied are small 9, 10, 11, and 12
The process should be discussed with the woman and booked at the 39/40 week VBAC clinic
appointment, or at an ANC appointment if under Consultant care. Unless clinically indicated, VBAC
IOL does not need to occur before 40+12. If the woman declines IOL, a post dates (40+12) ERCS
will be booked following discussion with an obstetrician.
Augmentation
The guideline on the use of Oxytocin (GL925) should be followed:
Procedure
One Propess only - Consultant
IOL PG
authorisation required
Yes - Consultant authorisation
IOL ARM + Oxytocin
required
No - Authorisation required from
Augment dysfunctional labour
delivery suite Consultant
Augment 2° arrest No
For augmentation of SROM await 24 hours then augment with Oxytocin.
No Propess
‘Non-conventional care’ for some women requesting VBAC

Women with prior CS delivery requesting intermittent auscultation of the fetal heart rate,
birth on the Rushey midwife-led unit or a home birth should be referred to the consultant
midwife. There should be a collaborative and non-judgemental approach to explore the
woman’s wishes and feelings and the reasons for her choice. There should be a clear plan
and explicit documentation of acting contrary to medical advice in the notes. A formal letter
should be sent to the woman and a brief case summary disseminated to the relevant staff,
including triage midwife and the community midwife.
Once in labour, all staff should be made aware of the birth plan. The unit co-ordinator,
consultant obstetrician on call should all be informed8.

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Postnatal Care
 Post-delivery, the woman should have the usual monitoring of maternal
observations, including vaginal loss. Digital palpation/ examination of scar is only
necessary if there is persistent postpartum bleeding.
 Ideally Women who have not achieved a VBAC should be given the opportunity to
discuss the reasons for CS and be provided with both verbal and printed
information about birth options for future pregnancies.
Auditable standards:
1. VBAC pathway for all women with a prior history of one uncomplicated lower-
segment transverse CS, in an otherwise uncomplicated pregnancy at term, with no
contraindications to vaginal birth is to be followed.
2. Pregnant women with a prior history of one uncomplicated lower-segment

transverse CS, in an otherwise uncomplicated pregnancy at term, with no
contraindications to vaginal birth will have a documented discussion about the
recommendation to have a VBAC
3. All women who have had one previous CS will be given the VBAC leaflet on mode
of delivery by the 20 weeks appointment.
4. All women whose planned mode of delivery is VBAC will have a plan made should
the labour not commence as planned/post EDD at the 40 weeks appointment. This
will be documented on the VBAC counselling checklist and follow the agreed plan
for IOL as per guideline.
References
1. RCOG Green-top Guideline No.45. 2015. Birth after previous Caesarean birth.
2. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat
caesarean section versus planned vaginal birth for women with a previous
caesarean birth. Cochrane Database of Systematic Reviews 2004, Issue 4. No.:
CD004224. DOI: 10.1002/14651858.CD004224.pub2.
3. Guise JM, Eden K, Emeis C, et al. 2010. Vaginal birth after caesarean: new
insights. Evidence Report/Technology Assessment; 191:1-397
4. UKOSS- Fitzpatrick K, Kurinczuk J, Alfirevic Z, Spark P, Brocklehurst P, et al.

(2012) Uterine Rupture by Intended Mode of Delivery in the UK: A National Case-
Control Study. PLoS Med 9(3): e1001184.
Doi:10.1371/journal.pmed.1001184
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5. National Collaborating Centre for Women’s and Children’s Health 2011. Caesarean
section. NICE Full guideline.
6. Kirkeby Hansen A, Wisborg K, Uldberg N, Brink Henriksen T. 2007.Risk of

respiratory morbidity in term infants delivered by elective caesarean section: cohort
study. British Medical Journal 2007; doi:10.1136/bmj.39405.539282.BE
7. Landon M, Leindecker S, Spong C, et al. (2005) The MFMU Cesarean Registry:

Factors affecting the success of trial of labour after previous caesarean delivery.
American Journal of Obstetrics and Gynaecology; 193: 1016-23
8. Dexter SC, Windsor S, Watkinson SJ. Meeting the challenge of maternal choice in
mode of delivery with vaginal birth after caesarean section: a medical, legal and
ethical commentary. BJOG 2014;121:133-140Al-Zirqi I, Stray-Pedersen B, Forsén
L, Vangen S. Uterine rupture after previous caesarean section. BJOG
2010;117:809-820
9. Williams MA, Luthy DA, Zingheim RW et al(1995) Production prostaglandin E2 gel

prior to induction of labour in women with previous caesarean section
10. Stone JL, Lockwood CJ, Berkowitz G et al (1984) use of cervical prostaglandin E2
in patients with previous CS.Br J Obstet Gynaecol 91: 7-10
11. Mackenzie IZ, Bradley S, Embrey MP(1997) Vaginal prostaglandins and labour
induction for patients previously delivered by caesarean section. Am J Perinatal 14:
157-160
12. Flamm BL, Anton D, Goings JR et al. (1987) prostaglandin E2 for cervical ripening:
multicenter study of patients with prior caesarean delivery. Obstet Gynecol 70: 709-
712

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Maternity Guidelines – Vaginal birth after caesarean (VBAC) guideline (GL930)
Appendix 1 – VBAC Counselling checklist (http://www.royalberkshire.nhs.uk/VBAC%20letters%20and%20proformas.htm)

Job Title: Consultant Midwife, VBAC Specialist MW Review Date: November 2019
Policy Lead: Group Director Urgent Care Version: V5.0 ratified 3/11/17 Mat CG mtg
Location: Policy hub/ Clinical/ Maternity / Intrapartum/ GL930
Maternity Guidelines – Vaginal birth after caesarean (VBAC) guideline (GL930)
Appendix 2 – VBAC pathway for women with one previous CS at booking and no
additional risk factors requiring consultant led care

Mat CG mtg

VBAC Guideline V5.0 GL930

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Vaginal birth after caesarean

section (VBAC) guideline (GL930)

Author: C Harding, J Bussey Date:

Author: C Harding, J Bussey Date: November 2017

 Approaching 40 weeks, women planning VBAC should have appointment at the

Benefits and harms of VBAC versus ERCS

The complication most usually cited by women is:

Author: C Harding, J Bussey Date: November 2017

Minor or transient complications of Caesarean birth

Blood transfusion and Infection

Respiratory morbidity in the neonate

Hypoxic ischaemic encephalopathy in the neonate

Author: C Harding, J Bussey Date: November 2017

Planned VBAC in special circumstances

Intrapartum care during planned VBAC

 An intravenous access assessment (to determine if cannulation would be difficult in

Signs and symptoms of scar rupture (one or more may be present):

Induction and Augmentation

‘Non-conventional care’ for some women requesting VBAC

Author: C Harding, J Bussey Date: November 2017

2. Pregnant women with a prior history of one uncomplicated lower-segment

4. UKOSS- Fitzpatrick K, Kurinczuk J, Alfirevic Z, Spark P, Brocklehurst P, et al.

6. Kirkeby Hansen A, Wisborg K, Uldberg N, Brink Henriksen T. 2007.Risk of

7. Landon M, Leindecker S, Spong C, et al. (2005) The MFMU Cesarean Registry:

9. Williams MA, Luthy DA, Zingheim RW et al(1995) Production prostaglandin E2 gel

Author: C Harding, J Bussey Date: November 2017

Appendix 1 – VBAC Counselling checklist (http://www.royalberkshire.nhs.uk/VBAC%20letters%20and%20proformas.htm)

Author: C Harding, J Bussey Date: November 2017

Author: C Harding, J Bussey Date: November 2017

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