Vaginal Birth after Caesarean

(VBAC)
Max Brinsmead MB BS PhD
May 2015

VBAC The Controversy

Once a Caesarean always a Caesarean

Edwin Cragin 1916
In an era of classical CS
Designed to prevent unnecessary primary CS

For 60 years Trial of (lower segment) scar

was standard British practice
But repeat CS more common in the US
Controversy broke out again in 2000
And it was all about fetal risks

VBAC The Controversy

Smith et al from Cambridge UK in JAMA 2002
Reviewed 313, 238 singleton births, 37 - 43w,
cephalic presentation in the Scottish Morbidity
Register 1992 -1997 excluding congenital
malformations and found
1. Rate of perinatal death 11 times higher for VBAC
compared to elective CS
2. This is 2 times higher than for multiparas having a
vaginal birth

VBAC The Controversy

Guise et al from Portland Oregan in BMJ July 2004
Reviewed 568 publications on VBAC vs elective
CS but found only 71 had useful data
Concluded that the additional risk of perinatal
death from attempted VBAC was 1.4 per 10,000
(95 percent confidence limits 0 - 9.8)
In only 5% of uterine ruptures did the baby die
This means that one has to perform 7142 elective
CS to prevent one baby death

This presentation will:

Examine the advantages and disadvantages
of VBAC
Evaluate the risks to mother & baby
Provide an evidence base for the safe
practice of VBAC...
Patient selection
Preparation of patients
Guidelines for intrapartum care

Advantages of VBAC

Greater maternal satisfaction

But its not all about me

Quicker recovery
But not always

Cheaper
But not much cheaper than elective CS and can
be much more costly

Less RDS for babies

But greater risk of death & disability

Less maternal morbidity and mortality

But these are rare with elective CS

Advantages of VBAC - 2

More vaginal births in the future

But whats the point if theres only to be two
kids!

Less maternal depression

But there is no evidence that this is so

Breast feeding more likely to succeed

Occurs in the delivery room
Easier for mothers without wound pain

Avoids risks unique to CS

But these are rare

Advantages of Elective CS

Certainty of timing
Thats the modern way!

Certainty of outcome
If I have a 30 50% chance of CS just do one!
Emergency CS more dangerous

Its Pain-free
More or less guaranteed!

Often preferred by fathers & obstetricians

Thats a male thing

Advantages of Elective CS

Protects the pelvic floor

Controversial because
Some risk arises from the pregnancy itself
And CS may not be protective

Safer for babies

But the absolute risk of VBAC is small

Avoids the risk of scar rupture

But there is much uncertainty about the
frequency of this
and the maternal and fetal risks

VBAC Risk to the Fetus

The rate of perinatal death is 11 x higher than

for elective CS
BUT
This risk is equivalent to that of being a fetus
to a Primigravida
The absolute risk is only 4.5 per 10,000 births
Confidence limits are wide
In the 2002 UK publication all emergency CS
were classified as attempted VBAC

Maternal Risk from VBAC

Meta analysis of risk of death

2.8 per 10,000 with trial of scar
2.4 per 10,000 for elective CS
No maternal death ever attributed to scar rupture

Scar rupture
Much confusion in the literature over the definition
Rate of asymptomatic scar rupture the same whether
VBAC or elect CS
Overall rate approx. 0.5% or 1:200
Was 0.35% in the largest combined contemporary study

Hysterectomy
Additional risk from trial of scar is 3.4 per 10,000
Requires 2941 elective CS to prevent one hysterectomy

Patient selection for VBAC

Type of previous CS
"10% " risk of rupture from classical and T incisions
Myomectomy and Hysterotomy

Indication for Previous CS

But 50-75% of patients can VBAC after previous CS for
CPD!

Previous obstetric history

VBAC success >90% if there has been prior vaginal birth
Dilatation at the time of previous CS
Gestation at previous CS was there a lower segment?

Number of previous CS
Increasing risk with increasing number

Patient selection for VBAC -2

Time since previous CS

Risk of scar rupture is 2 3x greater if <18m

Maternal weight
Miserable rates of VBAC for women >135 Kg

Lower uterine segment thickness

No uterine ruptures if >4.5 mm

Maternal Age
Clear evidence for declining uterine performance with age
at first labour

Family history of labour performance

A field ripe for study

Patient selection for VBAC - 3

Size of the mother and baby

But we are very bad at estimating this

Other pregnancy problems

Should be assessed according to obstetric principles

Engagement and cervical ripening

Best assessed at the onset of labour

Labour performance
Thats why its called trial of scar
Dilatation and descent
Progress rather than arbitrary time limits

Psychological Factors
The patients willingness and drive
The support provided

More than one previous CS?

Tahseen & Griffith BJOG Jan 2010 in a
systematic analysis of available data and
meta analysis concluded:
1.
2.
3.
4.

Overall success 71.1%

Risk of scar rupture 1.36% (this is 3x greater than
for one CS)
Perinatal risk is 0.09% (this is 3x greater than for
one CS)
The overall maternal morbidity was the same as
that for elective CS
Hysterectomy, transfusion, febrile morbidity etc

More than two previous CS?

Cahill et al BJOG 2010 in a retrospective
cohort study 89 women with >2 previous
CS concluded:
1.
2.
3.

Overall success 79.8%

No cases of uterine rupture
The overall maternal morbidity was the same as
that for elective CS
Hysterectomy, transfusion, febrile morbidity etc

Lower segment thickness and risk of scar rupture

Rozenberg et al Lancet 1996 studied 642 women with
ultrasound , measured the thinnest point of the lower
segment against a filled bladder, then attempted VBAC:

>4.5 mm - no ruptures or dehiscence (278)

3.6 - 4.5 mm 2% rate of scar rupture (177)
2.6 - 3.5 mm 10% rate of scar rupture (136)
<2.6 mm
16% rate of scar rupture (51)
Can be technically difficult particularly in obese woman
Vaginal and 3-dimensional measures promising

VBAC for the Obese?

Carrel et al (Am J OG in 2003) studied 70 women >200 lb,
70 who were 200-300 lb and 69 >300 lb

81.8% success for those <200 lb

57.1% success for those 200-300 lb
13.3% success for those >300 lb
Infection rate was:
5.7% group 1
11.4% group 2
39%
group 3
(Very similar results published in 2001)

VBAC for Older Women?

Byfield et al Am J OG in 2004 studied 659 women <30 years
age, 721 who were 30-35 years age and 370 >35 years age

72% success for those <30

71% success for those 30-35
65% success for those >35
Scar rupture rate was:
2.0% group 1
1.1% group 2
1.4% group 3

Pregnancy Interval and Risk of Scar Rupture

Byfield et al Am J OG in 2002 studied 1527 women who
attempted VBAC at <12 to >36 months after previous CS:

4.8% ruptured for those <12m

2.7% ruptured for those 13-24m
0.9% ruptured for those 25-36m
0.9% ruptured for those >36m

Pregnancy Interval and Risk of Scar Rupture

Bujold & Gauthier Obstet Gynec in 2010 studied 1768
women who attempted VBAC after one previous CS:

4.8% ruptured for those <18m

1.9% ruptured for those 18-24m
1.3% ruptured for those >24m

Also noted 7-fold increased rate of rupture

when the previous CS was a single layer
closure

Single vs Double-layer closure at prior CS

Blumenfeld et al BJOG in 2010 studied 127 women
undergoing primary CS.

At subsequent CS those who had a single

layer closure had a 7-fold increased risk of
bladder adhesions (RR=6.96, CI 1.72
28.1)
Regardless of any other variation in surgical
technique

Induction of Labour for VBAC?

Ravasia et al Am JOG 2000 studied 2119 women attempting
VBAC between 1992 and 1998 of whom 27% had an
induction of labour

Spontaneous labour
Induced labour
Cx ripening c PGs
Cx ripening c Foley
IOL not using PGs

0.45% scar rupture rate

1.4%
2.9%
0.7%
0.7%

Induction of Labour for VBAC -2?

Lyndan-Rochelle et al NEJM 2001 studied all women
attempting VBAC between 1987 and 1996 in Washington
state

Rate of Scar Rupture

No labour
1.6 per 1000
Spontaneous labour
5.2 "
"
Induced labour (not PGs) 7.7 "
"
Induced with PGs
24.5 " "
However this study used ICD9 codes for identifying scar
rupture and these are only 40% accurate

Induction of Labour for VBAC -3?

Lin & Rayner Am JOG 2004 studied 3533 women attempting
VBAC after one or more CS, 2523 in spontaneous labour,
438 by elective CS, 430 induced with oxytocin and 142
induced with Misoprostol

Rate of scar rupture was significantly higher

when labour was induced.
No significant difference between oxytocin
(0.8%) and Misoprostol (1.1%)

Induction of Labour for VBAC -4?

Dekkar et al studied 29,008 women attempting VBAC in
Australia 1998 2000 BJOG 117:1358 2010
Rate of scar rupture (complete & partial ) was:
No labour
Spontaneous labour with no augmentation
Labour augmented with oxytocin
Induced using oxytocin
Induced using prostaglandins (PGs)
Induced with PGs and oxytocin
Overall rate of successful VBAC

0.01%
0.15%
1.91%
0.54%
0.68%
0.88%
54.3%

Canadian College Surgeons & Physicians Guidelines 1993 - 1

Trial of labour should be recommended to

all women who have had only one previous
CS. Except for:
Previous classical, T or unknown uterine incision
Previous hysterotomy or full thickness myomectomy
Previous uterine rupture
Any contraindication to labour in this pregnancy eg
placenta previa, transverse lie etc.

The wish of the patient is paramount

(and the partner should ideally also be involved)

Canadian College Surgeons & Physicians Guidelines 1993 - 2

The patient should be made aware of the

hospitals resources and any limitations
The previous obstetric record should be
consulted
Consultation with a specialist obstetrician is
not mandatory
Induction of labour with oxytocin or Foley
catheter is acceptable
Augmentation with oxytocin is acceptable but
caution required if arrest has occurred in the
active phase of labour

Canadian College Surgeons & Physicians Guidelines 1993 - 3

Continuous EFM required only when when

induction or augmentation of labour is used
The problem of false positives
No evidence that it is a specific indicator of scar
rupture

Epidural anaesthesia not contraindicated

Twins not contraindicated
Suspected fetal macrosomia & diabetes not
contraindicated

My guidelines for VBAC - 1

Patients are counselled that VBAC is not

appropriate if:
There is a classical, T-shaped or unknown
uterine incision
More than one CS has been performed
The previous CS was performed for failure to
progress in the active phase of labour i.e. >4 cm
dilated
Their BMI is >35
Patients accepted outside of these guidelines on a case- bycase basis.

My guidelines for VBAC - 2

Patients who are suitable for a trial of scar
should be told by their primary carer that
elective CS and VBAC have risks and
benefits.
They should:

Read on the subject RCOG 2008

Discuss it with an obstetrician
Their decision will be respected

Patients planning VBAC require one to one

preparation

My guidelines for VBAC - 3

Any available record about the previous CS
is scrutinized
The patient is provided with individualised
chance of success with VBAC & maternal
and fetal risks
Delivery in a place capable of emergency
laparotomy is recommended
Any limitation in the patients chosen place
of birth is discussed
The discussion is documented

My guidelines for VBAC - 4

Offer IOL by sweep membranes, ARM and
oxytocin in safe working hours at 39 41w
Cervical ripening with Foley but not PGs
If admitted in spontaneous labour then
review by obstetrician within 2 hrs is
desirable
IV line, group and save
Epidural if required.
Monitor by continuous CTG only if
oxytocin or epidural is in use

My guidelines for VBAC - 5

CS is recommended if there is failure to

progress i.e.

<1 cm per hour dilatation over >4 hrs and >3 cm and
good uterine activity
No head descent with >60 minutes active pushing in
the 2nd stage
Assisted delivery may be attempted according to
usual obstetric dictates

OR Fetal Distress i.e.

Scalp lactate >4.8 or CTG so abnormal as to warrant

scalp sampling by RCOG guidelines

My experience with VBAC - 1

330 private multigravid patients 2001 04
65 had undergone previous CS (20%)
32 attempted VBAC (50%)
21were successful (66%)
12 by SVD and 9 assisted

My experience with VBAC - 2

Among the 32 VBACs there were:

2 patients who had 2 previous CS (one with a thin lower

segment)

5 patients whose previous CS was for failure to progress

and 2 of these had a bigger baby during VBAC

1 patient who had a third degree tear in her first SVD,

elective CS for the second and SVD with an intact
perineum during VBAC

Any Questions or Comments?

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