Birth after caesarean

Practice points

• Review details of the previous caesarean
• Discuss intentions for future pregnancies
• Provide women with information and advice on:
  • contraindications to and precautions for TOLAC (Table 1)
  • TOLAC and complicated pregnancies, if applicable (Table 2)
  • factors that increase the likelihood of successful TOLAC (Table 3)
  • benefits associated with modes of birth (Table 4)
  • risks of uterine rupture (Table 5)
  • other maternal, fetal and newborn complications (Table 6)
• Provide information early in pregnancy to facilitate informed decision making
• Document a management plan for intrapartum care
• Agree on a management plan for spontaneous labour, planned caesarean and EMCS
• Discuss a management plan if spontaneous labour does not occur by 40 weeks and provide information about the increased risk of uterine rupture associated with IOL
  (see: Induction of labour)
• Set date for caesarean and consent
• Routine antenatal care.

If planning for VBAC, ensure the hospital has the capacity to perform an emergency caesarean section and manage a uterine rupture.

• Review plan with the woman and revise as indicated
• Ensure:
  • IV access with a 16g cannula
  • blood sent for Group and Hold
  • record of progress on a partogram
  • continuous electronic fetal monitoring (CEFM)
• Inform anaesthetics, theatre, paediatric and nursery services of the woman's admission for TOLAC
• Provide continuous midwifery support with 1:1 care during established labour
• Oral intake as per normal intrapartum care
• Epidural analgesia is not contraindicated
• Escalate to senior obstetric clinician if there is a lack of progress in first or second stages
  • Refer to local intrapartum care guidelines for expected progress
• Active management of 3rd stage is recommended
• Routine exploration of the uterus to detect a dehisced scar after a vaginal birth is not recommended.

Remain alert for signs of uterine rupture:

• Prolonged, persistent, profound fetal bradycardia
• Abnormal FHR pattern suggesting fetal compromise
• Abdominal pain: acute onset of scar tenderness
• Any atypical pain:
  • chest pain
  • shoulder tip pain
  • pain previously controlled by analgesia
  • pain between contractions
• Cessation of previously efficient uterine activity
• Loss of station of presenting part
• Abnormal labour progress
• Vaginal bleeding
• Maternal tachycardia, hypotension or shock.

If there is any sign of uterine rupture, initiate emergency response as per local guidelines.

Practice points

• Offer the woman the opportunity to debrief with clinicians involved in her intrapartum care
• Offer referral to social work, pastoral or spiritual care as indicated
• Provide information about planning for the next birth
• Ensure that the woman's Maternal and Child Health Nurse and GP receive a complete discharge summary.

Women who have had a previous caesarean section should have the opportunity to make informed decisions about their care and treatment, in partnership with the clinicians providing their care.

Good communication between clinicians and women is essential. Treatment, care and information provided should:

• take into account women's individual needs and preferences
• be supported by evidence-based, written information tailored to the needs of the individual woman
• be culturally appropriate
• be accessible to women, their partners, support people and families and take into account any specific needs such as physical or cognitive disabilities or limitations to their ability to understand spoken or written English.

• RANZCOG
• RCOG

The following should be documented in the woman's hospital medical record and (where applicable) her hand-held medical record:

• details of the woman's previous caesarean - labour (if applicable), indication, type of incision
• management plan
• discussion of the risks and benefits of recommended management
• discussion of the woman's questions
• consultation, referral and escalation.

Audit and performance improvement

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

For further information, or assistance with auditing, please contact us via maternityehandbook@safercare.vic.gov.au

Auditable standards for Birth After Caesarean:

• number of women eligible to attempt TOLAC
• adherence to standards of care
• Perinatal Services Performance Indicator (PSPI) 4a - Rate of women who planned for vaginal birth following a primary caesarean section (Victorian maternity services)
• PSPI 4b - Rate of women attempting a VBAC who had a planned vaginal birth following a primary caesarean section (Victorian maternity services).

References

• Al-Zirqi I, Stray-Pedersen B, Forse´n L, Vangen S 2010, Uterine rupture after previous caesarean section. BJOG 2010;117:809-820
• Department of Health and Human Services 2017, Victoria's mothers, babies and children, 2014-2015
• Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D 2013, Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD004224. DOI: 10.1002/14651858.CD004224.pub3
• O'Neill et.al. 2017, Trial of labour after caesarean section and the risk of neonatal and infant death: a nationwide cohort study. BMC Pregnancy and Childbirth 17:74, DOI 10.1186/s12884-017-1255-2
• Queensland Health 2015, Vaginal birth after caesarean (VBAC)
• Royal College of Obstetricians and Gynaecologists 2015, Birth after previous caesarean birth. Green-top Guideline No.45
• Safer Care Victoria 2017, Victorian perinatal services performance indicators 2015-2016
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2015, Birth after previous caesarean section
• The Royal Women's Hospital 2015, Trial of labour (TOL) - Intrapartum management

Abbreviations