The Obstetrician & Gynaecologist 2007;9:2:77-82
doi: 10.1576/toag.9.2.077.27307
Copyright © 2007 by the Royal College of Obstetricians and Gynaecologists.
The current management of vaginal birth after previous caesarean delivery
Elizabeth Ball, MD PhD MRCOG, Senior Clinical Fellow1 and
Kim Hinshaw, MRCOG, Consultant Obstetrician and Gynaecologist2
1. St Bartholomew's Hospital West Smithfield, London EC1A 7BE, UK Email: ball.elizabeth{at}bartsandthelondon.nhs.uk (corresponding author)
2. Sunderland Royal Hospital, Kayll Road, Sunderland, Tyne and Wear, SR4 7TP, UK
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Abstract
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Key content:- Judicious promotion of vaginal birth after caesarean section (VBAC) is a reasonable strategy to counter the rising caesarean section rate.
- VBAC can achieve cost savings along with greater patient satisfaction.
- Appropriate augmentation of labour with oxytocin is not associated with an increase in scar rupture rate.
- Induction of labour with prostaglandin should be approached with caution as it is associated with an increased risk of scar rupture.
- With careful selection and monitoring, VBAC can be considered in twin pregnancy.
Learning objectives:
- To be aware of the specific level of risk of common complications associated with VBAC (including scar rupture) to facilitate appropriate counselling of women.
- To become familiar with evidence-based tools that can help predict the outcome of planned VBAC.
- To know the signs and symptoms indicating impending or acute scar rupture in order to be able to manage women undergoing VBAC safely in the intrapartum period.
Ethical issues:
- Should society be concerned about the trend towards normalising caesarean birth?
- To what degree should women be able to choose repeat caesarean section in the absence of a medical indication?
- Research confirms that the majority of women can safely achieve a vaginal delivery after one caesarean section. Should units with low rates of successful VBAC be expected to review and justify their outcomes?
Please cite this article as: Ball E, Hinshaw K. The current management of vaginal birth after previous caesarean delivery. The Obstetrician & Gynaecologist 2007;9:77–82.
Keywords caesarean section / risk management / trial of scar / uterine rupture / vaginal birth after caesarean section
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Introduction
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To address the continuing rise in the number of caesarean sections in the United Kingdom (currently at 21.5% of births), both the primary and repeat (accounting for 14% of the total number) caesarean section rates need to be reduced. Fifty-six percent of women attempt vaginal birth after one caesarean section, with 66.7% of them succeeding. In the UK, this means that only 33% of women who have had a previous caesarean section achieve a vaginal delivery.1 However, vaginal birth after caesarean section (VBAC) success rates of 74% have been stated in a recent Scottish report.2 Cost effectiveness calculations demonstrate financial savings from VBAC if success rates of 60–75% are achieved.3 Emergency caesarean section is more expensive than elective repeat caesarean section but the financial benefit relies on avoidance of any increase in costly adverse outcomes such as hysterectomy and cerebral palsy.
There is uncertainty and variation in counselling women for VBAC. This paper outlines strategies aimed at minimising adverse outcomes and maximising success rates, accepting that it is not possible to predict vaginal delivery with absolute certainty.4
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Limitations of studies regarding VBAC
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A number of problems complicate the design of randomised controlled trials. Firstly, the decision to opt for VBAC is highly dependent on the woman, her doctor's choice and local service provision. Furthermore, severe complications of VBAC are uncommon, hence most studies are not powered to detect the true incidence of rare but catastrophic events. Finally, available evidence stems from case control or retrospective observational studies with inherent problems of selection bias and limited comparability between study groups. Several studies also include asymptomatic uterine dehiscence, which does not impact on maternal and fetal outcome. In view of the paucity of grade A evidence and the difficulties associated with randomised controlled trials, the role of audit to inform best practice is paramount. Currently, there are two randomised controlled trials under way. The Australian Collaborative Trial of Birth After Caesarean (ACTOBAC) randomises women to elective repeat caesarean section and VBAC. In the follow-up study of the Caesarean Section Surgical Techniques (CAESAR) trial it is hoped, among other things, to review the impact of single versus double layer uterine closure on future scar integrity.
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Benefits of VBAC
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Maternal advantages from VBAC include a reduced incidence of blood transfusion, hysterectomy and maternal febrile morbidity (with the exception of chorionamnionitis)5 compared with elective caesarean section.6,7 These benefits are most obvious when successful VBAC is analysed separately. Failed VBAC is associated with the majority of complications.8 Following successful VBAC, time spent in hospital is halved, with a cost saving of £570 per woman.5 Finally, having experienced both modes of delivery, women generally prefer vaginal birth for future deliveries.9 However, there are no data on the attitude of women who have an unsuccessful VBAC. Minimising primary and repeat caesarean sections reduces the risk of peripartum hysterectomy,10 which is especially important in a younger primigravid population who plan to have future pregnancies.11
In VBAC there is less iatrogenic prematurity, transient tachypnoea of the newborn and respiratory distress syndrome than with elective repeat caesarean section.12 Iatrogenic prematurity can be improved if practitioners move the timing of elective caesarean section to 39 weeks of gestation.13 It is only when VBAC fails that the incidence of maternal problems such as sepsis is higher than in elective repeat caesarean section. Successful VBAC carries the same incidence of neonatal morbidity as normal vaginal delivery.12
Conversely, multiple caesarean sections are associated with an increased likelihood of dense pelvic adhesions, placenta praevia and placenta accreta with their associated intraoperative risks.14–16
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Risks of VBAC
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Three major studies5–8 and two meta-analyses7,17 of VBAC report an increased risk of uterine rupture compared with elective repeat caesarean section (OR 2.10, CI 1.45–3.05).7 To avoid one symptomatic uterine rupture, 370 elective caesarean sections would have to be performed.17
Fetal acidosis (OR 2.24, CI 1.29–3.88)7 and hypoxic encephalopathy are more common in VBAC.8 The incidence of fetal death was increased in VBAC in three retrospective reports6,7,17 (OR 1.71, CI 1.28–2.28) but not in a prospective study.8
The risk of maternal thromboembolic complications6 and hysterectomy in VBAC appears to be reduced (OR 0.39, CI 0.27–0.57)7 or unchanged,5,8 but the hysterectomy rate for uterine rupture is increased by 3.4/10 000.17 There is no apparent increase in maternal death, although no study is powerful enough to draw firm conclusions. In a large multi-centre trial, the maternal mortality rate within the VBAC group of 0.2:1 000 was similar to that observed in controls; causes were not directly related to the mode of delivery.8 The rate of maternal deaths related to uterine rupture alone is 0.02:1 000.18
In spite of doubling of risk for some complications, absolute numbers remain low. Based on a review of 142 075 VBACs, Chauhan et al.18 determine three levels of risk which are useful when counselling women (Table 1).18 Fetal and maternal complications – uterine rupture in particular – have a strong association with the failure of VBAC.8 In the UK the relative risk of uterine rupture is 2.76.1,3 Landon et al.8 report the increased risks in failed, compared with successful, VBAC with regard to uterine rupture, hysterectomy, blood transfusion and endometritis (Table 2).
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Table 2
Maternal complications: different modes and outcomes of delivery. (Copyright @ 2004 Massachusetts Medical Society. All rights reserved.)8
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Uterine rupture is associated with an increase in fetal complications, including arterial cord pH of less than 7.0 (33%), hypoxic ischaemic encephalopathy (6.2%) and neonatal death (1.8%).8 A recent series from the Netherlands from predominantly small units observed a higher perinatal death rate of 11.7%.10 In cases of uterine rupture, neonates appear to do best in the following situations:8,19,20- when delivered in large units
- when there is a smaller degree of fetal extrusion into the abdominal cavity leading to less fetal acidosis
- when delivery is achieved within 18 minutes of the onset of prolonged fetal heart decelerations.
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Diagnosis of uterine rupture
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Because of the marked improvement in neonatal and maternal outcome, speedy diagnosis of uterine rupture is essential. Cardiotocography heralds uterine rupture in 50–70% of cases:21 changes include bradycardia, tachycardia, reduced baseline variability, severe late decelerations, tachysystole or disappearance of contractions.22 Other more variable findings include continuous uterine or abdominal pain, loss of station of the presenting part, vaginal bleeding, haematuria and hypovolaemia.23 Reassuringly, epidural anaesthesia rarely masks scar pain but signs and symptoms of uterine rupture can be confused with acute placental abruption.24
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Factors affecting the outcome of VBAC
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A lower segment uterine scar, whether transverse or longitudinal (the latter incision is not often performed in the United Kingdom), does not influence maternal or neonatal outcome.24 However, a previous classical caesarean or T-shaped scar has been linked to scar rupture in 4–9% of VBACs;21 in addition, previous hysterotomy and myomectomy with opening of the uterine cavity are usually considered to be contraindications to VBAC. It is important to confirm the uterine scar type from the woman's history and from the previous notes. Very preterm caesarean section indicates the possibility of a classical caesarean section scar.25
In VBAC of twins there is a three to five-fold increase in scar dehiscence but no difference in major morbidity and mortality and over 70% of women will deliver vaginally.26 Maternal age is inversely related to the success of VBAC27 and directly related to uterine rupture,28 as is obesity where the weight is more than 135 kg (which is also associated with an increased incidence of infectious morbidity).29 Fetal macrosomia greater than 4 000 g reduces the VBAC success rate without increasing the rate of uterine rupture.30 However, women without prior vaginal deliveries have the lowest success rate.31 Intrauterine pressure catheters are poor predictors of uterine rupture32 and there is still uncertainty concerning the clinical value of pre-labour ultrasound scanning.33 A short interdelivery interval of less than 12 months has been reported to be associated with a five-fold increase in uterine rupture,34 although these findings were not consistent with other studies. The risk of uterine rupture is greatest with the first VBAC and decreases with further VBACs.35 Safe VBAC can be also achieved in grand multiparous women with a history of one caesarean section.36 Contrary to popular belief, elective caesarean section is not automatically required when first delivery is a failed attempt at operative vaginal delivery in an occipitoanterior position. In a retrospective study where ‘true disproportion’ was strictly defined, 68% of women delivered vaginally in their next pregnancy.37
Meticulous partographic documentation of labour progress in a VBAC is mandatory since, 1 hour after crossing the ‘alert line’ with cervical dilatation of less than 1 cm/hour, the risk of uterine rupture increases by a factor of 10.38
Augmentation
The need for augmentation is associated with a decrease in successful VBAC. With one exception,39 most recent studies report no increase in feto–maternal morbidity and mortality with oxytocin augmentation.40,41 However, careful surveillance and a low threshold for caesarean section remain necessary, particularly with suspected dystocia.21
Induction of labour
Currently, 18% of labours in the United Kingdom are induced1 but reports on safety of induction of labour (IOL) in VBAC are conflicting and randomised controlled trial evidence is urgently needed. Women who have never delivered vaginally are at the highest risk from uterine rupture following IOL.42 Interestingly, IOL-associated uterine ruptures occur mainly in the first stage of labour and prostaglandins appear to have a direct weakening effect on the scar, causing rupture at the scar site. Oxytocin is more usually associated with defects remote from the old scar.43 Complication rates vary according to induction agent. Prostaglandin IOL is associated with a 15.6-fold increase in risk of uterine rupture compared with the risk in women undergoing repeat caesarean delivery without labour.44 The largest study on prostaglandin use in VBAC reported a relative risk of 1.42 (CI 1.26–1.6) of uterine rupture compared with spontaneous onset VBACs.2 Macones et al.41 observed that it was the sequential use of prostaglandin and oxytocin that conveyed an increased risk of uterine rupture.
An alternative to IOL with prostaglandin is the use of a Foley catheter to initiate cervical dilatation. This is not associated with an increase in uterine rupture rates compared to amniotomy with or without oxytocin, but is less successful in effecting vaginal delivery (55% compared with 78%).45 The role of misoprostol in inducing labour for VBAC remains undefined, as the small studies that have been conducted reach different conclusions with regard to the safety of this drug. General rules for managing VBAC are summarised in Table 3.
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Models predicting VBAC outcome
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Older statistical models that have been applied to predict VBAC success are of limited use in antenatal counselling because they include intrapartum factors, such as cervical dilatation >4cm at admission to the delivery suite and no need for augmentation.4,8 A validated, user-friendly and robust assessment tool now exists, based on 23 000 women, which includes only antenatal criteria.2 As in screening for trisomy 21, women with term pregnancies attempting VBAC can be categorised into low (<20%), intermediate (20–40%) and high (>40%) risk for emergency caesarean section. Negative predictors for VBAC success include: small stature, advanced maternal age, male baby, prostaglandin IOL, no previous vaginal delivery and post-dates gestation. It is important to note that post-date attempts at VBAC carry a higher rate of failure (OR 1.36, CI 1.24–1.50) but no increase in the risk of uterine rupture.46
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Maternal choice
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Over the last decade, following the publication of Changing Childbirth47 and the Winterton Report,48 women have been taking a more active role in decisions affecting their own obstetric care. Women may prefer an elective repeat caesarean section to VBAC in spite of their doctors' enthusiasm for promoting VBAC, thus keeping VBAC rates below the potential rates achievable.49 When counselling women on the mode of delivery after caesarean section, doctors should take into account further planned pregnancies. Elective caesarean section appears to be associated with a lower peripartum hysterectomy rate when there is only one further pregnancy. However, if more children are planned VBAC carries a lower risk of subsequent peripartum hysterectomy.11 Obviously, the absolute risks remain extremely small.
Reasons for declining VBAC may include concern about pelvic floor function, the inability to make domestic arrangements in advance or fear of pain. However, over 50% of women who experienced both modes of delivery felt that the postoperative pain after caesarean section was more severe compared with their vaginal delivery.9 In contrast to professionals who assess risk statistically and who may consider a perinatal mortality rate in VBAC of 0.4/1 000 low and acceptable, lay people judge risk according to ‘dread,’ determined by their perception that the unwanted outcome is irreversible, potentially lethal and uncontrollable.50
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Conclusion
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Successful VBAC is a desirable outcome for mother and newborn. VBAC failure, resulting in emergency caesarean section and, rarely, in uterine rupture, can be minimised with appropriate patient selection, good antenatal counselling, careful review of the case notes and adherence to written guidelines. Senior, technical and logistical backup on the labour ward will also minimise this risk. Even in the rare case of uterine rupture, catastrophic maternal and fetal consequences can be minimised by prompt diagnosis and rapid resort to emergency caesarean section. New statistical approaches will help to identify those women who are likely to succeed in VBAC and this may help their decision-making.
Good practice recommendations
In view of the risk management issues associated with VBAC, we would recommend the antenatal care pathway shown in Box 1.
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References
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Abstract
Introduction
