VAGINAL DELIVERY AFTER

CAESAREAN SECTION
(VBAC)


GROUP A1
SCENARIO:
A 28 years old G2P1, currently at 36
weeks gestation has been regularly attending
antenatal clinic as advised.
Her previous delivery was by an elective
Caesarean section at term, due to breech
presentation.
She is concerned about mode of delivery in
current pregnancy which remained uneventful
throughout.

A.:What further details of history
and clinical findings are relevant
to be elaborated in her case?
BY : Ngee Wey Yi
1. Antenatal history Important for establishing risk
in the current pregnancy.
2. Maternal age Currently she is 28 years old
(usually >30 years old female would probably at
risk of uterine rupture)
3. Maternal height It correspond to the size of the
pelvic. (small size mother will have difficulty in
labour due to small size pelvic)
4. BMI It indicates whether the mother is obese or
not. (VBAC is less successful in obese women
weighing over 90 kg)
5. Weight of baby Usually overweight baby can be
seen in diabetic mothers.



6. When was the previous caesarean section done? (to make
sure that she does not conceive another child within the
recovery period of approximately 18 months after the C.
Section)

7. How was her labour progress?(normal / abnormal labour)
- Progress in labour is dependent on three variables:
(i) Powers(effeciency of uterine contractions)
(ii) Passenger(fetus, with respect to its size, presentation
and position)
(iii) Passages(uterus, cervix, bony pelvis)
- Any abnormalities in the variables will affect the labour
process.

8. What type of caesarean section was done?
(Classical/ transverse)
-Past -Caesarean sections used a vertical incision
which cut the uterine muscle fibres in an up and down
direction (a classical Caesarean).

-Modern Caesareans typically involve a horizontal
incision along the muscle fibres in the lower portion
of the uterus (hence the term lower uterine segment
Caesarean section).

- VBAC is contraindicated if more than 2 LSCS were
done previously.
9. Was there any operative or post-operative
operation complication?
a) Intraoperative complications
- Bowel damage
- Haemorrhage
- Placenta previa
-Urinary tract damage
b) Post operative complications
- Infections and endometritis
- Pulmonary emboli and deep vein thrombosis

Clinical features which impedes VBAC
Abnormal CTG
Severe abdominal pain, especially in between contractions
Incisional hernia and wound infection
Chest pain/SOB/shoulder tip pain
Maternal tachycardia, hypotension, shock.
Vaginal bleeding
Loss of station of presenting part
Fetal distress
women who delivered their first child by
Caesarean delivery had increased risks for:-
-Malpresentation
- placenta previa
-antepartum hemorrhage
-placenta accreta
-prolonged labor
-uterine rupture
-preterm birth, low birth weight, and stillbirth in their
second deliveries.
By :Pariksit Rao
B: Will any additional investigations be
required also?

Ultrasound :
-Presentation
-Cephalopelvic disproportion (CPD)
-Placenta previa
-Macrosomal baby
-Twin gestation
Full blood count
-Hb (11.0)
-WBC (6 -14)

Cardiotocography
-Nonreassuring fetal heart tracing

PCR Blood test
-Genital herpes

Modified GTT at 24-28 weeks
-Gestational Diabetes Mellitus
C :Risks And Benefits Of Vaginal
Birth After Caeserean (VBAC)
BY : Nalinah
BENEFITS
For mother:
o Faster recovery
o Lower maternal chance of risks related to having
an operation
For baby:
o Breathe more easily
o Begin breastfeeding sooner which can help with
the overall success of breastfeeding



RISKS
Uterine rupture
Hysterectomy
Perinatal death
Perineal tearing

Risks and Benefits of Elective repeat
caesarean section(ERCS)
BY: Hui Rou
Benefit
Daytime services when hospital resources are optimal, and the ability to plan
and prepare for the event.

Reduction in the risk of fetal death or liveborn infant death

Reduction in the risk of major maternal haemorrhage and/or the need for blood
transfusion compared with planned VBAC.

The risk of scar rupture in women with a prior scar, it reports, was greater in
women having VBAC labors compared with women planning repeat cesareans.

No need to undergo a series of contraction pain in labour process.


Risk
Premature or compromised delivery.

Babies delivered by elective repeat cesarean section delivery are
nearly twice as likely to be admitted to the neonatal intensive care
unit (NICU) than those born vaginally after the mother has
previously had a c-section

Women planning ERC are at increased risk of surgical
complications, placenta accreta, and risks of multiple
caesareans and their infants are at risk of respiratory morbidity

Couple may experience subsequent infertility.

Hysterectomy

Deep vein thrombosis

Blood transfusion

Hospital Stay

Placenta Problems increases with no. of CS (eg.
Placenta previa and Placenta accreta)
Caesarean section is associated with risks of postoperative
adhesions, bowel and urethral injuries, incisional hernias (which
may require surgical correction) and wound infections

Adhesions can cause complications, such as:
Infertility
Chronic pelvic pain
Small bowel obstruction
BY:Priscilla and Jaspreet
D :Discuss the criteria that help
in choosing the specific mode of
delivery for her

1.Spontaneous labour
2.Interpregnancy interval less than 2 years ago.
3.Low age and body mass index (Not obese)
4. Previous vaginal delivery [not applicable]
5. Previous Caesarean section had been
performed electively (for breech presentation) or
for fetal distress, as opposed to dystonia.


CRITERIA FOR VAGINAL DELIVERY..
1.Vertical uterine scar
2.Multiple previous Caesareans (not applicable)

Other absolute indications for Caesarean section



CONTRAINDICATIONS FOR VAGINAL
DELIVERY..
1. Previous Caesarean section
2. Dystocia
3. Malpresentation
4. Suspected acute fetal compromise
5. Others- multifetal pregnancy, placenta
praevia, fetal disease and maternal
disease.
INDICATIONS FOR REPEAT CAESAREAN
SECTION..
1. Weakened uterine wall
2. Bladder injuries
3. Heavy bleeding
CONTRAINDICATIONS FOR REPEAT
CAESAREAN SECTION..
No list can be truly comprehensive and
whatever the indication, the overriding
principle is that whenever the risk to the
mother and/or fetus from vaginal delivery
exceeds that from operative intervention,
a Caesarean section should be undertaken
BY : Min See and Joo Jien
E. Intrapartum Management


On admission

Ongoing management:
First Stage
Second Stage
Third Stage

On admission

Inform registrar on admission to birth suite of all
women who have a uterine scar.
The registrar must refer to the Women's VBAC
Antenatal Assessment form to review and revise the
management plan prepared antenatally in
consultation with the woman.
Notify anaesthetist of any patient for planned VBAC
in birth suites and in labour.
IV access with cannula from onset of labour.
Blood to be taken for:
Blood group and Hb



Ongoing management

ARM to be performed once the cervix is:
3cm dilated
Effaced
Continuous Electronic Fetal Monitoring
throughout the labour.
Aim to deliver within 12 hours of onset of
active labour.

First Stage:

Vaginal Examination every 4 hrs until 7cm
dilated, and 2-hourly thereafter. Record the
findings at each assessment.
Progress: anticipate 1 cm dilatation / hour
(after achieving 3cm). Discuss progress with
on-call obstetric consultant if less.
In general, oxytocin augmentation is not
contraindicated in women undergoing a VBAC.
Plans to augment must be discussed with the
on call obstetric consultant prior to
commencement of a syntocinon infusion.

Second Stage
Notify registrar when cervix considered to be
fully dilated.
Duration should not exceed 2 hours: 1 hour to
allow for passive descent, but no more than 1
hour of active pushing (or 30 minutes if the
woman has had a prior vaginal delivery).
The option of any mid-cavity assisted vaginal
delivery must be discussed with the consultant.
No mid-cavity assisted delivery to be
performed without the consultant being
present, and then to be performed in the
operating theatre.

Mid-cavity Head 1/5 palpable
per abdomen.
Leading point is
above +2, but not
above the ischial
spines.
Third Stage

Minimising risk of inadvertent administration

Oxytocin administration

Controlled cord traction (CCT)

Birthing the placenta and membranes

Immediate post birth management

Minimising risk of inadvertent administration

Keep the checked drug vial and syringe containing the
oxytocic away from the neonatal resuscitator /cot to
minimise inadvertent administration to the neonate.

Oxytocin administration

Preferred over other uterotonic drugs

Clamp and cut the umbilical cord within 2-3
minutes of administration of the oxytocic.

Place one hand on the uterine fundus and
await the onset of a strong uterine
contraction.




Controlled cord traction (CCT)
Place one hand above the level of the symphysis
pubis, applying counter pressure in an upward
direction, thus stabilising the uterus during CCT.
guarding the uterus.

Birthing the placenta and membranes

Once the placenta is visible at the vaginal orifice:
Release cord traction
Release counter traction on the fundus
As the placenta emerges, slowly pull it out to
complete third stage.

Immediate post birth management

Palpate the fundal height and massage the fundus every
15 minutes for first hour following birth of placenta and
membranes.
Monitor PV bleeding.
If the vaginal bleeding is excessive, determine the cause
(4Ts)
Ensure early repair of any perineal/cervical trauma.
Examine placenta and membranes for completeness. If a
portion of the maternal surface is missing or there are
torn membranes with vessels, suspect retained placenta
fragments. Refer to a medical officer for further
management.
Document the findings.

F:Is the previous scar at any risk?
How do we detect that ?

BY : Nishanthini
Uterine rupture
Definition- tear in uterus
Cause- trauma, labor with an unusually
big baby, multiple gestation, and vaginal
delivery after a prior C-section (in which
the old C-section scar ruptures).

Single low transverse (further
subcategorized by 1-layer or 2-layer
hysterectomy closure)
Single low vertical
Classic vertical
Multiple previous cesarean deliveries
Uterine scar status
Sign & symptoms
TAS & TVS sonohysterographic
Pelvic examination
Amniography & radiopelvimetry
CT / MRI
How do we detect the risk?
G :CONSEQUENCES OF
ELECTIVE REPEAT CESEARIAN
ON FUTURE PREGNANCIES
BY : Menaga
Placenta praevia presence of placental tissue over or
adjacent to the cervical os
leading cause of antepartum haemorrhage (vaginal
bleeding)

Placenta praevia
abnormally deep attachment of the placenta,
into the myometrium
Types : placenta accreta, placenta increta,
placenta percreta
great risk of haemorrhage during its removal
Severe forms can often lead to a hysterectomy
placenta accreta
Involve small or big tear that results in the fetus
and placenta pouring into the abdominal cavity
occur when the incision scar expands and tears
during pregnancy or labour
Patient will have abdominal pain and vaginal
bleeding
Neonatal respiratory distress
mother need a blood transfusion and possibly a
hysterectomy

Rupture of uterus

Adhesion = bands of scar tissue
Usually cause the organs to stick to each other
and results in pain as movement is limited
Occasionally, it can lead to fertility problem as
adhesion can block or press on the fallopian tube
Scar tissue-difficult to make hole in uterus-
operation longer time
Increased chance of accidental cut in bladder or
bowel of mother
Risk of adhesion
Preterm birth
Breech presentation
Low birth weight

Other complications in subsequent
pregnacies.