The Princess Alexandra Hospital NHS Trust

16 Pages·2013·0.09 MB·English

by  Christine Cook

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THE PRINCESS ALEXANDRA HOSPITAL NHS TRUST

DIRECTORATE OF WOMEN’S HEALTH & MIDWIFERY SERVICES

LABOUR WARD MULTI-DISCIPLINARY GUIDELINES

BIRTH AFTER PREVIOUS CAESAREAN

Version: 4
Ratified by: Patient Safety and Quality Team
Date ratified: 28th January 2013
Name of author: Mr Elwakil, Associate Specialist
Name of sponsor: Jacqui Featherstone: Head of Midwifery
and Nursing Women’s and Children’s
Health
Date issued: January 2013
Review date: January 2016
Name of reviewer: Miss Khan: Labour Ward and CNST
Lead Consultant
Anna Peacock Labour Ward
Manager/Matron
Sue Callaghan: Midwife
Target audience: All Obstetricians, Midwives & nurses

Name………………………………………… Signed………………………………………
Lead Obstetrician – Patient Safety and Quality Team

Name………………………………………… Signed………………………………………
Head of Midwifery and Nursing Women’s and Children’s Health Patient Safety and Quality
Team

Name………………………………………… Signed………………………………………
Lead Obstetric Anaesthetist - Patient Safety and Quality Team

Name…………………………………………. Signed………………………………………
Supervisor of Midwives – Patient Safely and Quality Team

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Contents

Section Page

1 Guideline Development- 3
Purpose, Stakeholders, Implementation, Training

2 Introduction 4

3 Antenatal Counselling 5

4 Planned VBAC in special circumstances 6

5 Induction of Labour 6

6 Management of Labour 7

7 Management of Second Stage Labour 8

8 Signs of possible uterine rupture 8

9 Indications for repeat caesarean sections 8

10 Management of Scar Dehiscence 8

11 Auditable Standards 9

12 Audit/Monitoring Process 9

13 References 10

14 Associated Documents 10

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Guideline development

Purpose

To provide evidence based information to inform the care of women undergoing either
planned vaginal birth after previous caesarean section (VBAC) or elective repeat caesarean
section (ERCS).

Development Process/Stakeholders

This guideline has been updated by an Associate Specialist in line with recommendations
from the RCOG Guidelines on birth after a previous caesarean section. The consultation
process involved multidisciplinary meetings between Obstetricians and Midwives. The
guideline was also sent for comments to the Obstetric Consultants, Midwifery Managers,
Supervisors of Midwives and as with all new and revised guidelines, it was sent to the
Maternity Services Liaison Committee lay representatives for comments prior to being
ratified at the Maternity Patient Safety and Quality Team Meeting and finally the guideline is
noted and endorsed by the Trust Patient Safety & Quality Committee.

Implementation

This guideline can be found within the guideline folders situated in the Labour Ward office. A
master copy in paper form is kept by the Risk Coordinator Midwife and in electronic form by
the Head of Midwifery’s PA. It is also available in electronic version available to all staff by
accessing the Trust Policies icon on the desktop or public folders/Intranet. Information on
new and updated guidelines is disseminated through the women’s Health newsletter, ward
managers, Supervisors of Midwives and Clinical tutors/Lead Doctors. The previous version
is archived both in paper and electronic format.

Training

Midwives have the opportunity to attend sessions on promoting normality, which includes
birth after previous caesarean section.
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Birth after previous caesarean

Introduction

Women with a prior history of one uncomplicated lower-segment transverse caesarean
section, in an otherwise uncomplicated pregnancy at term with no contraindication to vaginal
birth, should be able to discuss the option of planned vaginal birth after caesarean (VBAC)
and the alternative of a repeat caesarean section (ERCS) as early as possible in the
pregnancy or in the puerperium of the previous pregnancy.

• ERCS is recommended in women who have had one classical caesarean section. In
most cases where women had two caesarean sections, an elective section is
recommended unless the woman has special views which need to be discussed with a
senior obstetrician and documented in the woman’s notes.

• A final decision for mode of birth should be agreed with the woman before her expected
delivery date (ideally by 36 weeks of gestation).

• If the woman who is booked for VBAC does not go into spontaneous labour by 41
weeks, she should be seen by the obstetrician to discuss the induction process and
risks, prescribe the induction agent and document the management plan in the health
care records.

• A plan for the event of labour starting prior to ERCS including mode of delivery should
be documented in the notes. This is particularly important if women initially choose
VBAC but change their mind at the 36/40 appointment, as with further discussion the
women may elect to continue with VBAC if they go into spontaneous labour before their
ERCS date.

• Women requesting a caesarean section in the absence of any clear medical indication
are managed according to best practice guidance. The reasons, concerns and fears
underlying a woman’s request are explored, discussed and recorded. A second opinion
may be needed if there is no agreement about the appropriate mode of delivery. The
reason for performing a caesarean section should be stated on the consent form.

Each woman must have an individual management plan for labour documented in their
maternity records by either the VBAC midwife or member of the obstetric team by 36/40 of
pregnancy, which should include:-

• Antenatal discussion on mode of delivery

• Place for labour

• Plan should labour commence early

• Plan for labour should this not commence as planned.

• Plan for monitoring the fetal heart in labour

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Antenatal Counselling

All women who have had a previous caesarean section whether they have other pregnancy
related risk factors or not should be referred to the VBAC clinic to be seen by a VBAC
midwife early in pregnancy where the benefits and risks of VBAC should be explained. The
VBAC midwife should have accurate information on the reasons for the previous caesarean
section before discussion. Women should be given time and encouragement to discuss
their own feelings about delivery, so that any specific concerns can be addressed. All
women should receive the local information leaflet before their appointment at the VBAC
clinic.

If the woman has additional pregnancy risk factors, she will be referred to attend the
Tuesday obstetric antenatal clinic when ever possible to coincide with the VBAC clinic to
avoid the woman having to attend on two separate occasions.

Women who are undecided or require further counselling will be offered the opportunity to
attend the VBAC clinic again at 28/40.

All women should be seen again at 36/40 by the VBAC midwife or consultant clinic
(depending on pregnancy risk factors) to assess fetal growth and presentation, confirm
mode of delivery and document management plan for labour.

Women booked for VBAC should be offered a stretch a sweep at 40 weeks and given an
obstetric appointment at 41 weeks to discuss the induction process, prescribe the induction
agent and document the labour management plan.

Women considering VBAC should be informed that overall chance of a successful vaginal
birth is 72-76% (Guise J M etal 2004).

• Factors associated with successful VBAC:

- Previous vaginal birth – best predictor

• Factors – associated with unsuccessful VBAC are:
- No previous vaginal birth.
- BMI >30
- Previous caesarean for shoulder dystocia
- After 41 weeks of gestation
- Birth weight greater than 4000gms
- No epidural anaesthetic.
- Previous pre-term caesarean section.
- Cervix dilated at admission – less than 4cm.
- Less than 2 years from previous birth.
- Advanced maternal age.
- Non-white ethnicity.
- Short stature.
Women should be given detailed information about risks and benefits of vaginal delivery
after caesarean section compared to ERCS.

Risks of VBAC:-

1. Women considering the option for vaginal delivery after a previous caesarean section
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carry a risk of uterine rupture of 1:200. There is usually no risk of uterine rupture in
women undergoing ERCS (Landon et al 2004, Turner et al, 2006).

2. It has been reported that women who are having VBAC have 1% additional risk of either
blood transfusion or Endometritis than women having ERCS.

3. Women considering VBAC carry a 2 – 3/10,000 additional risk of birth related perinatal
death when compared with ERCS. The absolute risk of such birth related perinatal loss
is comparable to the risk of women having their first birth.

4. Women considering VBAC should be informed that they have a risk of 8/10,000 that the
infant develops Hypoxic Ischaemic Encephalopathy compared to infants born by ERCS.
The long term effect on the infant is unknown.

Benefits of VBAC:-

1. Women considering the option of VBAC should be informed that attempting VBAC
reduces the risk that their baby will have respiratory problems after birth: rates are 2-3%
with planned VBAC and 3-4% with ERCS.

2. ERCS may increase the risk of serious complications as placenta accrete, injuries to
bladder, bowel or ureters, ileus, blood transfusion and duration of operative time and
hospital stay. (W U S et al, 2005, Silver RM, et al, 2006).

3. In VBAC the woman recovers quicker and stays a shorter time in hospital.

4. In VBAC the incidence of thrombo-embolism is less than after ERCS.

Planned VBAC in special circumstances

1. Women who are preterm and considering the option for VBAC, should be informed that
planned preterm VBAC has similar success rates to planned VBAC at term, but with
lower risk of uterine rupture.

2. A cautious approach is advised when considering planned VBAC in women with twin
pregnancy, foetal microsomia, and short inter-delivery interval, as there is uncertainty in
the safety and efficacy of planned VBAC in these situations.

3. Women who request a home birth must be counselled about the risks. If after
counselling the woman still wishes to have a home birth, the woman should be
supported as much as possible with an individual plan of care and any discussions
clearly documented.

Induction of Labour

Decision and mode of induction should be taken by an experienced obstetrician. The
Consultant should be informed.
• All women choosing VBAC should be offered a stretch and sweep at term and again at
their 41/40 appointment to reduce the need for induction of labour.
• If pregnancy is progressing normally, induction is planned for term +12 days to maximise
the opportunity for the spontaneous onset of labour.
• Women should be told that there is 2-3 fold increased risk of uterine rupture and 1.5
times risk of caesarean section in induced and/or augmented labours compared with
spontaneous labours.
• Prostaglandins are not contraindicated but should be used with extra precaution.
Women should be informed that there is a higher risk of uterine rupture with induction of
labour with prostaglandins. If one dose is unsuccessful further management should be
discussed with the Consultant.
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Management of Labour

Women should be advised that planned VBAC should be conducted in the labour ward
where there is appropriate staff and equipment and available resources for immediate
caesarean section and advanced neonatal resuscitation. Women who request a home birth
must be counselled about the risks. If after counselling the woman still wishes to have a
home birth, the woman should be supported as much as possible with an individual plan of
care and any discussions clearly documented.

1. The Registrar on call should be notified and plan of management should be documented
in the maternity notes.

2. Canulation is not necessary unless there are other risk factors

3. Women can eat and drink normally in early labour. Once in established labour women
should be encouraged to take high calorie (isotonic) drinks.

4. Progress of labour should be carefully assessed using the partogram.

5. There should be careful serial cervical assessments (4hrly), preferably by the same
person, for both augmented and non-augmented labours, to ensure that there is adequate
cervical dilatation thereby allowing the planned VBAC to continue.

6. ARM should only be performed if at any stage labour is not progressing satisfactorily.
Women should be encouraged to mobilise and adopt whatever positions make them
comfortable for labour.

7. Augmentation of labour by syntocinon should be used with caution and the woman
should be counselled by the most senior obstetrician on the labour ward. The
consultant should be involved in the decision making. Contractions should not exceed 3 -
4 in 10 or last more than a minute

8. There is no direct evidence to recommend what is acceptable cervical dilatation in
women being augmented with a previous caesarean section. Among women with
unscarred uterus, it is suggested that there is unlikely to be a higher vaginal birth if
augmentation continues beyond 6-8 hours. In view of increased risk of uterine rupture in
women with prior caesarean section, more conservative threshold is adopted for the
upper limit of augmentation by syntocinon (Hamilton E.F, et al, 2001).

9. No contradiction for epidural anaesthesia.

10. Women should be advised to have continuous fetal monitoring once in established
labour as an abnormal CTG is the most consistent finding in uterine rupture and is
present in 55-87% of cases.

11. Women who choose to opt for intermittent monitoring need to be advised of the rationale
for continuous fetal monitoring, which is recommended by NICE in order to ensure they
have made an informed choice. This should be clearly documented in the labour plan,
during the antenatal period. Women, who after counselling still request intermittent fetal
monitoring whether on dry land or who choose water for pain relief or a water birth
should be encouraged to have a CTG. This should be performed at the beginning of
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labour or prior to entering the pool. Those women opting for the water should be cared
for in the labour ward and not on the birthing unit. The discussion on the risks and a clear
management plan should be documented during the antenatal period and on admission
to labour ward.

Management of Second Stage of Labour

The duration and progress in the second stage should be carefully monitored. There must
be evidence of descent of the presenting part and a satisfactory fetal monitoring. When
epidural analgesia is used for pain relief or the fetal head needs to descend a passive
second stage is acceptable to allow descent of the presenting part. A diagnosis of delay in
the active second stage should be made when it has lasted one hour. The woman must be
referred at this stage to the obstetric team or earlier if there has been no progress, who
should then carry out a physical assessment and document a plan of care with the possibility
of instrumental delivery if vaginal birth is not eminent. Birth would be expected to take place
within two hours of the start of the active second stage.

Signs of possible uterine rupture

There is no single pathogenic clinical feature that is indicative of uterine rupture but the
presence of any of the following signs should raise the concern for the possibility of rupture:-

a) abnormal CTG
b) Severe abdominal pain, especially if persisting between contractions.
c) Chest pain or shoulder pain, sudden onset of shortness of breath.
d) acute onset of scar tenderness
e) abnormal vaginal bleeding or haematoma
f) cessation of previously efficient uterine activity
g) maternal tachycardia, hypotension or shock
h) Loss of station of the presenting part.

Indications for repeat caesarean sections

1. Slow progress of labour
2. Inadequate descent of the head
3. Signs of scar rupture.
4. Fetal distress.
5. Failed induction.

Management of Scar Dehiscence

If rupture of the scar is suspected, emergency caesarean section is indicated. The on call
consultant for labour ward should be informed immediately and assistance is requested.

Further management either repair of the tear or hysterectomy will depend on the extent of
the tear. Detailed and accurate description of the findings should be documented in the
patient notes and debriefing of the patient and her family should be undertaken by a senior
obstetrician.

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Auditable Standards

VBAC success rate

VBAC midwife or obstetric involvement in:-

• Documented discussion of risks and benefits of VBAC and ERCS

• Documented antenatal discussion on the mode of delivery

• Documented plan for labour should this commence early or not as planned

• Documented individual management plan for labour, including place for labour and
monitoring of fetal heart in labour

Documentation of Consultant involvement in:-

• Deciding to induce or augment labour

• Establishing a plan for induction or augmentation (such as preferred vaginal
examination interval, expected minimal progress and the criteria needed to discontinue
labour and proceed to emergency caesarean section)

Audit/Monitoring Process

- Responsibility
The VBAC midwives will be responsible for monitoring/auditing implementation of these
guidelines.

- Frequency
A continuous & ongoing audit of the success rate for women choosing VBAC is in place.

An Annual audit against the documentation standards

- Methodology
A retrospective audit of 1% of health records of women who have a history of a previous
caesarean section, identified from the birth register chosen at random from the previous
three months deliveries will be audited against the auditable standards.

- Monitoring deficiencies
The audits results are presented for review and discussion at the maternity multidisciplinary
Governance and audit meetings. Results, minutes and recommendations are disseminated
to all Stakeholders unable to attend through Ward Managers, Supervisors of Midwives and
the Clinical Tutors/Lead Doctors. Where deficiencies are identified an action plan will be
formulated and monitored by the VBAC midwives.

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References

• Momgen V, Halfuerk M., et al 1998: Vaginal Delivery After Previous Ceasarean Section
For Failure of Second Stage of Labour. Br. J. Obstet, and Gynaecol, 1998, Vol. 105, 10:
79-1081.

• Landon M B, Hauth J C, Levens K J, Spong Cy et al. Maternal and prenatal outcomes
associated with a trial of labour after prior caesarean delivery. N Eng L J Med 2004,
351:2581-9.]

• Turner M J, Agnew G, Langan H. Uterine repture and labour after a previous low
transverse caesarean section. BJOG 2006; 113:729-32.

• Guise J M, Berlin M et al. Safety of vaginal birth after caesarean: a systematic review.
Obstet Gynecol 2004; 103:420-9.

• W U S, Hibbard J U et al. Abnormal placentation: twenty year analysis. A M J Obstet
Gynecol 2005; 192:1458-61.

• Silver R m et al. Maternal morbidity associated with multiple repeat caesariean
deliveries. Obstet Gynecol 2006; 107:1226-32.

• Hamilton E F, McNamarah, Platt R W. Dystocia among women with symptomatic
uterine rupture. A M J Obstet Gynaecol 2001; 184:620-4.

• NICE Guideline intrapartum care management and delivery of care to women in labour.
1.14 (pages 51-52)

• RCOG Birth after previous caesarean birth. Green-top Guideline No 45 February 2007.

Associated Documents

PAH Local vaginal Birth after Caesarean Section information leaflet
PAH Normal Labour Guidelines
PAH Induction of Labour Guidelines

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