Vaginal birth after caesarean section (VBAC) - Queensland Health

Vaginal birth after caesarean section (VBAC) - Queensland Health

Department of Health Maternity and Neonatal Clinical Guideline Vaginal birth after caesarean section (VBAC) Queensland Clinical Guidelines: Vagina...

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Department of Health

Maternity and Neonatal Clinical Guideline

Vaginal birth after caesarean section (VBAC)

Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) Document title:

Vaginal birth after caesarean section (VBAC)

Publication date:

June 2015

Document number:

MN15.12-V4-R20

Document supplement:

The document supplement is integral to and should be read in conjunction with this guideline

Amendments:

Full version history is supplied in the document supplement

Replaces document:

MN09.12-V3-R14

Author:

Queensland Clinical Guidelines

Audience:

Health professionals in Queensland public and private maternity services

Exclusions:

Management of uterine rupture

Review date:

June 2020

Endorsed by:

Queensland Clinical Guidelines Steering Committee Statewide Maternity and Neonatal Clinical Network (Queensland) Email: [email protected]

Contact:

URL: www.health.qld.gov.au/qcg Disclaimer This guideline is intended as a guide and provided for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect. The guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from the guideline, taking into account individual circumstances may be appropriate. This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for: • • •

• • • •

Providing care within the context of locally available resources, expertise, and scope of practice Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary Ensuring informed consent is obtained prior to delivering care Meeting all legislative requirements and professional standards Applying standard precautions, and additional precautions as necessary, when delivering care Documenting all care in accordance with mandatory and local requirements

Queensland Health disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable. © State of Queensland (Queensland Health) 2015

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en For further information contact Queensland Clinical Guidelines RBW H Post Office, Herston Qld 4029, email [email protected], phone (07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479.

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Page 2 of 16

Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) Flowchart: Next birth after caesarean section

Next birth after caesarean section Antenatal • Shared decision making • Discussion ≤ 20-24 weeks: - Support maternal preferences - Capabilities of the facility - Previous birth information - Individual risks & benefits - Obtain informed consent - Document • Consider anaesthetic review • Preferably one obstetrician visit by 36 weeks or by 32 weeks if antenatal transfer of care required • Document plan of care

Is planned vaginal birth appropriate?

Elective repeat CS No

(At 39-40 week, if clinically appropriate)

Yes

Yes

Uterine rupture – signs and symptoms • Prolonged, persistent and profound bradycardia • Abnormal FHR pattern suggesting fetal compromise • Abdominal pain, acute onset of scar tenderness • Abnormal progress in labour, prolonged first or second stage of labour • Vaginal bleeding • Cessation of previously efficient uterine activity • Loss of station of the presenting part • Chest pain or shoulder tip pain • Maternal tachycardia, hypotension or shock

Induction of labour?

No

Induction of labour • Document obstetric and maternal shared decision making • Requires caution due to increased risk of uterine rupture • Prostaglandin and Oxytocin: - Obtain informed consent as contraindicated by manufacturer

Intrapartum admission • Review medical chart (including prior CS report) and labour care plan • Notify obstetric team • Notify anaesthetic and theatre staff • Insert ≥ 16 gauge intravenous cannula • Group & hold, full blood count • One-to-one midwifery care • Continuous fetal monitoring • For intrapartum care: - Refer to QCG: Normal birth

Is augmentation appropriate?

No

No

Is the progress of labour satisfactory?

Yes

Augmentation • Discuss with obstetric team • Refer to QCG: Normal birth • Consider: - Supportive measures - Artificial rupture of membranes - Oxytocin infusion: ▪ Refer to IOL box

Emergency CS

No

Is the progress of labour satisfactory?

Yes

Yes

Vaginal birth

Definitions: CSCF:Clinical services capability framework; CS:Caesarean section; FHR:Fetal heart rate; IOL: Induction of labour; ≤: less than or equal to; ≥: greater than or equal to Queensland Clinical Guideline (QCG): MN15.12-V4-R20 Vaginal Birth after caesarean section (VBAC)

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Page 3 of 16

Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) Abbreviations ARM

Artificial rupture of membranes, amniotomy

BMI

Body mass index

Cat 1

Category 1 emergency caesarean section

CEFM

Continuous electronic fetal monitoring

CS

Caesarean section

ERCS

Elective repeat caesarean section

IOL

Induction of labour

VBAC

Vaginal birth after caesarean section

VBAC-2

Planned vaginal birth after caesarean section with two prior caesarean sections

Definitions Continuity of carer

Where the same health professional or professionals provide care throughout a woman’s contact with maternity services, including pregnancy, 1 birth and the postbirth period.

Elective repeat caesarean section (ERCS)

Planned caesarean birth by a woman who has had one or more prior caesarean births, whether or not the previous caesarean births were 2 electively scheduled or not.

Neonatal respiratory morbidity

Combined rate of transient tachypnoea of the newborn and respiratory distress syndrome.

Next birth after caesarean section

Refers to a woman’s next birth after a previous caesarean section (CS).

Obstetrician

Local facilities may as required, differentiate the roles and responsibilities assigned in this document to an “Obstetrician” according to their specific practitioner group requirements; for example to General Practitioner Obstetricians, Specialist Obstetricians, Consultants, Senior Registrars and Obstetric Fellows.

Planned VBAC

Planned VBAC (vaginal birth after caesarean) refers to the plan to birth vaginally, rather than by ERCS by the woman who has experienced a prior 3 caesarean birth.

Primary caesarean section

The first CS a woman has.

Shared decision making4

Shared decision making involves the integration of a woman’s values, goals and concerns with the best available evidence about benefits, risks and uncertainties of treatment, in order to achieve appropriate health care decisions. It involves clinicians and patients making decisions about the woman’s management together. In partnership with their clinician, patients are encouraged to consider available screening, treatment, or management options and the likely benefits and harms of each, to communicate their preferences, and help 4 select the course of action that best fits these.

Uterine dehiscence

Disruption of the uterine muscle with intact uterine serosa.

Uterine rupture

Disruption of the uterine muscle extending to and involving the uterine serosa or disruption of the uterine muscle with extension to the bladder or 3 broad ligament.

VBAC

Vaginal birth following one or more previous CSs; also known as successful VBAC; refer to definition of ‘Planned VBAC.’

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5

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) Table of Contents Introduction ............................................................................................................................... 6 1.1 Purpose ............................................................................................................................ 6 1.2 Queensland context .......................................................................................................... 6 1.3 Woman-centred care and shared decision making ............................................................ 6 1.4 Service capability .............................................................................................................. 6 1.5 Recommendations and implementation............................................................................. 7 2 Care following the primary/prior CS ........................................................................................... 7 3 Antenatal care........................................................................................................................... 7 3.1 Discussion and planning ................................................................................................... 8 3.2 Planned VBAC.................................................................................................................. 8 3.2.1 Contraindications .......................................................................................................... 8 3.2.2 Considerations .............................................................................................................. 9 3.2.3 Likelihood of VBAC ....................................................................................................... 9 3.3 Potential benefits and harms of VBAC and ERCS ............................................................. 9 3.3.1 Potential benefits of VBAC ............................................................................................ 9 3.3.2 Potential harms of planned VBAC ............................................................................... 10 3.3.3 Potential harms of ERCS ............................................................................................ 10 3.3.4 Timing of ERCS .......................................................................................................... 11 3.3.5 Induction of labour ...................................................................................................... 11 4 Intrapartum care...................................................................................................................... 11 4.1 On admission.................................................................................................................. 12 4.2 Maternal and fetal assessment........................................................................................ 12 4.3 Discomfort and pain ........................................................................................................ 12 4.4 Fetal heart rate monitoring .............................................................................................. 12 4.5 Indications for additional care .......................................................................................... 12 4.5.1 Augmentation of labour ............................................................................................... 12 4.5.2 Uterine rupture – signs and symptoms ........................................................................ 13 4.6 Second stage of labour ................................................................................................... 13 5 Postpartum care...................................................................................................................... 13 References .................................................................................................................................... 14 Acknowledgements ........................................................................................................................ 16 1

List of Tables Table 1. VBAC and ERCS considerations including uterine rupture .................................................10 Table 2. Two prior caesarean sections (VBAC-2): Planned VBAC and ERCS .................................. 10 Table 3. Potential harms of ERCS ...................................................................................................11 Table 4. Planned VBAC and IOL considerations ..............................................................................11 Table 5. Augmentation of labour considerations ..............................................................................13

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC)

1

Introduction

The increasing rate of primary caesarean section (CS) has led to an increased proportion of women 6 with a history of previous caesarean birth. The options for the next birth include: • A planned vaginal birth after caesarean (VBAC) which will result in either a vaginal birth or an emergency CS; or • An elective repeat CS (ERCS) 7 There are infrequent, significant clinical harms with both planned VBAC and ERCS. Clinical 8 outcomes are determined mainly from epidemiological studies and one randomised control trial 9 (n=22). Findings from a large systematic review concluded planned VBAC is a reasonable and safe choice for most women, however, there are individual specific considerations which may increase the 7 potential harms associated with planned VBAC. Facilitating shared decision making will enable 4 women to make informed decisions about their birth options.

1.1

Purpose

This guideline provides assistance for clinicians to care for and support women: • In their decision making about their next birth after CS • Planning a VBAC

1.2

Queensland context

In 2013 in Queensland, 118 per 1000 women, at term gestation, experienced their next birth after 10 primary CS where : • 719 per 1000 women had a repeat CS with no labour • 632 per 1000 women who spontaneously laboured had a VBAC (women who subsequently had a CS for reason of a uterine scar from previous surgery were excluded, as a proportion of these women would have had an ERCS if there was no spontaneous labour) • 678 per 1000 women who were induced had a VBAC • The recorded uterine rupture rate for the women who spontaneously laboured or were induced was 5 per 1000 women

1.3

Woman-centred care and shared decision making

Woman centred care and shared decision making enables women to feel empowered in making decisions, based on the woman’s individual needs and preferences and the best available evidence 4 of potential benefits and harms, in partnership with care providers. Supporting women with their decision making for their next birth after CS includes the principles of11: • Shared decision making4, incorporating o Clinicians having counselling skills and access to consistent evidence-based information in order to support women to make an informed choice o Providing women with consistent evidence-based information about their next birth after CS 12 • Access to planned VBAC services

1.4

Service capability

Offer planned VBAC in maternity services in accordance with the current Clinical Services Capability 13 Framework. Whilst site specific guidelines may be required to reflect resources and the ability of the 3,14,15 : birthing facility to respond to emerging situations, ensure the service is capable of providing • Access to an emergency CS16,17 including clearly defined Category 1 CS (Cat 1)18 policy/workplace instruction and processes 16 • Continuous intrapartum monitoring 19 • One-to-one midwifery care during labour 16 • Advanced neonatal resuscitation 16,17 • Onsite blood transfusion • 24 hour anaesthetic services

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC)

1.5

Recommendations and implementation

Guideline recommendations and information on implementation, including audit, are provided in the accompanying Supplement: Vaginal birth after caesarean (VBAC) accessed via http://www.health.qld.gov.au/qcg/.

2

Care following the primary/prior CS

Following a primary/prior CS, and before going home, offer all women the opportunity to talk and 17 discuss their birth experience : • Preferably with the medical officer who performed the CS and the primary midwife involved in the woman’s care 17 • The woman may prefer to discuss at a later date • More than one discussion may be required Include in the discussion: • Any labour and birth concerns (including unplanned events) 20 • Identification of emotional needs 17 • Reason for the CS • Unexpected events during the CS/preceding labour 3 • Planning future pregnancies and births , including: o Contraception o A recommended minimum 18 month interval from CS to VBAC7 o Information regarding the next mode of birth o Intra-pregnancy weight management improves the probability of VBAC21 17 Provide the woman , her midwife (if appropriate) and General Practitioner with written information regarding the above discussion with a copy in the woman’s clinical record.

3

Antenatal care

Ensure all women have access to individualised next birth after CS advice and care planning throughout pregnancy, including: • An antenatal discussion prior to 20–24 weeks [refer to Section 3.1] 3 • At least one antenatal visit, preferably with an obstetrician for discussion and planning before or at: o 34-363 weeks o 32 weeks for rural services if antenatal transfer to another service is anticipated • With a multidisciplinary team, and continuity of carer (e.g. Midwifery Group Practice) where available o Discuss, consult and refer according to professional guidelines If individualised care planning is not available at the local facility, refer according to local and 22 professional consultation and referral guidelines

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC)

3.1

Discussion and planning

Shared decision making about the next birth after a previous CS should take into consideration: • Maternal preferences and priorities17, including: o The number of intended future pregnancies16 as longer term risks (e.g. placenta praevia, placenta accreta) increase after each subsequent CS • The capabilities of the maternity service14 [refer to Section 1.4]: o If the local hospital cannot provide VBAC services, offer the women the opportunity to transfer to a hospital that offers planned VBAC  Refer to local and professional consultation and referral guidelines22 o If a woman makes choices outside of those recommended in this clinical guideline or beyond the service capability of the chosen place of birth15: 23  Consider within the ethical frameworks of autonomy and beneficence  Ensure the woman is informed of the potential increase of harm due to the diminished availability of resources and staff, including obstetric, paediatric, anaesthetic, pathology, and operating theatre  Develop management plans as required (e.g. for uterine rupture)  Refer to local frameworks and processes • Previous birth information including the indication for the previous CS, and the operation report to verify the type of uterine incision, previous uterine closure technique, and any perioperative complications o Ideally obtain the operation report prior to the initial discussion with the woman  As it can be difficult to access operative notes performed at other facilities, request early in pregnancy • Potential maternal and perinatal benefits and harms of VBAC and ERCS in the context of a woman’s individual circumstances24,17 [refer to Sections 3.2 and 3.3] • Explanation of the reason(s) if VBAC not advised • The birth plan, including: o Intrapartum care [refer to Section 4 Intrapartum care] o The possibility circumstances may change and ERCS/emergency CS may be required to be offered with consideration of vaginal birth and CS in the birth plan • Written information (e.g. decision aids) and/or reputable internet sites accessible by the woman • Interpreters where required • Access to culturally competent care including Indigenous maternity health care models and Indigenous workers for Aboriginal and Torres Strait Islander women and families • Document: o The discussions (including above) in the woman’s clinical record o The woman’s acknowledgement of the discussion (may be included on a VBAC or ERCS consent form – refer to local facility) o The decision regarding mode of birth and the agreed plan of care, including if labour 25 commences before the expected ERCS date o If required, the interpreter’s name and/or identification number who facilitated the discussion

3.2

Planned VBAC

3.2.1 Contraindications Ascertain and document if contraindications for VBAC are present. Contraindications include: • Maternal or fetal reasons to avoid vaginal birth in current pregnancy14,24 3,16,24 • Previous uterine incision other than lower transverse segment 3,24 • Previous uterine rupture 14 • Previous hysterotomy or myomectomy entering the uterine cavity

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) 3.2.2

Considerations • Previous CS: o Classical incision associated with increased risk of uterine dehiscence/rupture7 o The uterine rupture and dehiscence risks are not significantly different between single and double layer closure techniques26,27, however:  Locked single layer uterine closures have been associated with higher risks of uterine rupture and dehiscence when compared to unlocked single layer and 26,28 double layer closures • Where the pregnancy interval (birth to due date/actual birth date) is less than 18 months, discuss the increased risk of uterine rupture7,29 • VBAC after two previous CS (VBAC-2) – refer to Table 2 • Multiple pregnancy or suspected fetal macrosomia requires consultation with an obstetrician • Exclude low-lying placenta praevia and accreta – referral to a tertiary facility may be required for assessment • The role of ultrasound in predicting risk of rupture is uncertain and not routinely recommended, however: o There is a strong negative correlations between lower uterine segment thickness and 30 risk of uterine defect (thinning, dehiscence or rupture) , and  Although an ideal thickness has not been determined, a myometrial lower uterine segment thickness of greater than 2.0 mm provides a strong negative predictive 30 value for a uterine defect

3.2.3 Likelihood of VBAC 7 Planned VBAC success is generally in the range of 60–80%. Factors which increase vaginal birth occurring include: • Previous vaginal birth, whether before or following the CS, is a strong predictor7,29 with a VBAC rate approaching 90%25 3,29 • Younger maternal age 7 • Caucasian/white ethnicity 2 7 • Body Mass Index (BMI) less than 30 kg/(m ) o Weight loss increases VBAC success in women who were overweight or obese before their first CS birth21 • Prior CS indication not related to arrest of labour25 7 • Spontaneous onset of labour at less than 41 weeks gestation 3,29 • Cervical dilatation greater than 4cm on admission 7 • Birth weight less than 4 kg

3.3

Potential benefits and harms of VBAC and ERCS

VBAC and ERCS have differing risks and benefits for women and their babies. There is insufficient high level evidence in regards to the benefits and harms of planned VBAC and ERCS. 3.3.1 Potential benefits of VBAC Compared to CS, women having a VBAC have: • Shorter stays in hospital7,17,29 29 • Lower rates of deep vein thrombosis 29 • Enhanced mother-infant bonding, including the long term wellbeing of the infant 5 • Lower maternal morbidity • Infants with a gut microbiota that is causally linked with greater protection from allergic 31 disease

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) 3.3.2

Potential harms of planned VBAC • Planned VBAC which results in vaginal birth is associated with fewer complications than 15 an ERCS • Planned VBAC which results in an emergency CS is associated with more complications 15 than an ERCS • Absolute risk of birth related perinatal loss with planned VBAC is comparable to the risk 3 for women having their first baby • Refer to Table 1 for VBAC and ERCS considerations • Refer to Table 2 for planned VBAC considerations after two CSs • Refer to Table 4 and Table 5 for induction and augmentation of labour considerations

Table 1. VBAC and ERCS considerations including uterine rupture

Consideration Uterine rupture • Total • Spontaneous labour without Oxytocin augmentation • Second pregnancy – first birth an emergency CS • Second pregnancy – first birth a planned CS Subsequent to uterine rupture • Maternal mortality • Hysterectomy • Perinatal mortality • Neonatal morbidity (hypoxic ischaemic encephalopathy) o Subsequent neonatal mortality • Neonatal morbidity at term gestation Other • Maternal infection • Perinatal mortality

Number per 1000 women (95% CI) VBAC ERCS 7 0.4 (0.2–1.1)7 4.7 (2.8–6.8) 32

1.9 (1.1–3.2) n/a 33 2 0.433 333 0.733 7 Number per 1000 uterine ruptures Nil 140–330 60 62 18 0–28 Number per 1000 women (95% CI) VBAC7 ERCS7 63 (34–101) 39 (23–58) 1.3 (0.6–3) 0.5 (0.07–3.8)

Table 2. Two prior caesarean sections (VBAC-2): Planned VBAC and ERCS

Consideration • VBAC • Uterine rupture • • • • •

Hysterectomy Transfusion Febrile morbidity Perinatal morbidity Neonatal unit admission

3.3.3

Number per 1000 women (95% CI) 34 34 VBAC-2 ERCS 711 n/a 13.6 (0–54) 1.1 15 (9–18) 5.5 6.3 20 17 6 6.4 0.9 0.1 84.9 88.5

Potential harms of ERCS 7 • Maternal mortality is significantly higher with planned ERCS and may increase with each subsequent CS • Future pregnancy complications of CS include placenta praevia and placenta accreta o Placenta accreta morbidity includes:  Excessive blood loss  Potential need for hysterectomy  Complications associated with surgery  Maternal mortality17 • Refer to Table 3. Potential harms of ERCS

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) Table 3. Potential harms of ERCS

Consideration • Maternal mortality o Maternal mortality at term gestation • Hysterectomy • Transfusion • Fever Other • After 2 CS – placenta praevia • After 2 CS – placenta accreta • After 3 CS – placenta praevia • After 3 CS – placenta accreta

Per 1000 women (95% CI) VBAC7 ERCS7 0.04 (0.01–0.2) 0.13 (0.04–0.4) 0.02 (0.004–0.1) 0.10 (0.02–0.4) 1.7 (0.1–2.4) 3.1 (0.2–4.9) 8.8 (4.2–15.1) 11.6 (6.4–18.3) 66 (44–93) 102 (49–170) 17 Per 1000 women (95% CI) 11–23 2–9 18–37 8–17

3.3.4 Timing of ERCS For babies born by CS, the risk of respiratory morbidity decreases after 39 weeks, therefore, 17 schedule ERCS after 39 weeks. 3.3.5

Induction of labour 16 • Induction of labour (IOL) requires caution and documented obstetric and maternal shared decision making and is required • Risk of uterine rupture is increased [Refer to Section 3.3.2 and/or Table 4] • Transcervical catheter is the clinically preferred method for IOL • To note, although widely used in clinical practice, previous uterine surgery is a 35,36 therefore manufacturer contraindication for the use of Oxytocin and Dinoprostone informed consent is required

Table 4. Planned VBAC and IOL considerations

IOL consideration Any induction method Any gestational age Term VBACs and IOL Post term and IOL Mechanical – transcervical catheter and/or artificial rupture of membranes (ARM) Prostaglandin (PGE2) Prostaglandin and Oxytocin Oxytocin Oxytocin and indication for prior CS: FTP and CPD Fetal distress Malpresentation/breech

Per 1000 women (95% CI) VBAC achieved Uterine rupture 7 630 (590–670) 12 (9–16)7 107 157 7 32 (i) 6.3 (0.8–22.4) (i) 612 (ii) 540 (490–590) (ii) (i) 514 (i) 6.8 (1.9–17.4) (ii) 630 (580–690) (ii) 20 (11–35) (i) 602 (i) 17.7 (4.8–44.7) (i) 645 (i) 8.2 (3–17.7) (ii) 620 (530–700) (ii) 11 (9–15) 7 540 (480–600) 7 600 (490–690) 750 (600–860)7 -

(i) Australian review32; (ii) International systematic review7 Abbreviations: CI: Confidence interval; FTP: Failure to progress; CPD: Cephalo-pelvic disproportion

4

Intrapartum care

Provide intrapartum care as per the Queensland Clinical Guideline Normal Birth.37 Refer to the following sections for planned VBAC specific care.

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC)

4.1

On admission

It is important to remember that the way in which care is given, and the environment in which it is provided, has a significant impact on the woman and her partner's experience of childbirth and her 11 subsequent emotional wellbeing. The woman may change her choice of birth mode to CS or planned VBAC at any stage, either antenatally or in labour, and support their choice by informed 38 discussion. • Notify and consult the medical obstetric team/medical officer when a woman presents for planned VBAC14 • Review the plan of care prepared antenatally in consultation with the woman and revise if necessary 19,37 , as: • Provide one-to-one midwifery care o Associated with improved birth outcomes o To enable prompt identification and management of uterine scar dehiscence or rupture3,14 • An intravenous cannula16 of sufficient size to allow rapid resuscitation (16 gauge or larger) is recommended from the onset of labour • Collect bloods: o Blood group and hold3,16 o Full blood count • Notify anaesthetist and operating theatre of any patient for planned VBAC in birth suites and in labour. Take into account local arrangements/policy.

4.2

Maternal and fetal assessment

In addition, to routine assessment and observations37, assess: • Vaginal examination with informed consent: o Within 1 hour of admission, and then o Once labour is established:  4 hourly/if indicated until 7 cm dilated, then consider  2 hourly/if indicated after 7 cm dilatation • Maintain close surveillance: o Utilise partogram with warning and action lines to aid assessment of progress o Observe for signs and symptoms of uterine dehiscence or rupture [refer to Section 4.5.2] • Refer to the National Consensus Statement: essential elements for recognising and responding to clinical deterioration39

4.3

Discomfort and pain

Water immersion will depend on the availability of continuous electronic fetal monitoring (CEFM) suitable for water immersion.

4.4

Fetal heart rate monitoring 3

Following the onset of uterine contractions, CEFM is recommended. An abnormal fetal heart rate is 3 the most consistent finding in uterine rupture. [Refer to the Queensland Clinical Guideline 40 Intrapartum fetal surveillance.

4.5

Indications for additional care

4.5.1 Augmentation of labour If indicated, the use of ARM and/or Oxytocin to augment labour must be discussed with the woman and obstetrician prior to commencement. • If there is a delay in progress and in the active stage of labour, perform ARM prior to consideration of Oxytocin augmentation [refer to Queensland Clinical Guidelines Normal birth37, and Induction of labour41] • Oxytocin augmentation is associated with: o An increased risk of uterine rupture [refer to Table 5] and should be used with caution o A VBAC rate of 68% (95% CI: 64–72%) (strength of evidence is low)7 o A history of previous uterine surgery is a (manufacturer recognised) contraindication36:  Obtain informed consent and document in the woman’s notes Refer to online version, destroy printed copies after use

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) Table 5. Augmentation of labour considerations

Per 1000 women (95% CI)

Consideration

VBAC achieved • Spontaneous labour onset – Oxytocin augmentation 32

Uterine rupture

(i) 616 (ii) 680 (640–720)

(i) 19 (10–33) (ii) -

7

(i) Australian review ; (ii) International systematic review

4.5.2 Uterine rupture – signs and symptoms Uterine rupture may occur at any stage of labour and can occur during pregnancy or postpartum. 42 There are no reliable clinical markers or models that predict uterine rupture. The signs and symptoms of uterine rupture are typically non-specific, some are rare and some may be associated 42 43 with other obstetric circumstances , making diagnosis of uterine rupture difficult. Assess in the context of the woman’s individual circumstances. There are no reliable clinical signs or symptoms that predict the timing of uterine rupture. Category 1 Caesarean Section is required for suspected uterine rupture as there is an urgent threat to the woman and her baby.18 The most common sign of uterine rupture is: 43 • Prolonged, persistent and profound bradycardia which occurs in approximately 80% of 42 7 cases and is associated with poor perinatal outcomes Other non-specific signs and symptoms may include: • Abnormal fetal heart rate pattern42,43 suggesting fetal compromise44 43 • Abdominal pain, acute onset of scar tenderness 44 o Pain may continue between contractions • Abnormal progress in labour43, prolonged first or second stage of labour43 43 • Vaginal bleeding 43,44 , including hyperstimulation42 and/or in• Cessation of previously efficient uterine activity coordinate contractions 43 • Loss of station of the presenting part 45 • Chest pain or shoulder tip pain (particularly in the absence of vaginal bleeding) 43 43 42,43 • Maternal tachycardia , hypotension or shock

4.6

Second stage of labour

Reassess and consult obstetrician if duration exceeds: • 1 hour for passive descent, and/or o 1 hour for the active stage in the woman who has not been in the active stage previously o 30 minutes of the active stage in the woman who has previously laboured through second stage active labour

4.7

Third stage of labour

Routine exploration of the uterine scar is unnecessary and is not recommended

5

14

Postpartum care

Women should be offered the opportunity to discuss the implications for future pregnancies of their birth experience. This discussion may be assisted by an interpreter and/or an Indigenous health worker where appropriate. Refer to Section 2 Care following the primary/prior CS.

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC)

References 1. National Health and Medical Research Council (NHMRC), Department of Health and Ageing, Australian Government. National guidance on collaborative maternity care. Canberra: NHMRC; 2010. 2. National Institutes of Health. National Institutes of Health Consensus Development conference statement: vaginal birth after cesarean: new insights March 8-10, 2010. Obstet Gynecol. 2010; 115(6):1279-95. 3. Royal College of Obstetricians and Gynaecologists. Birth after previous caesarean birth. Guideline No. 45. 2007. Available from: http://www.rcog.org.uk. 4. Australian Commission on Safety and Quality in Health Care. Shared decision making. 2014 [cited 24 November 2014]. Available from: http://www.safetyandquality.gov.au/our-work/shared-decision-making/. 5. Landon M, Hauth J, Leveno K, Spong C, Leindecker S, Varner M, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004; 351:2581-9. 6. Kolokotroni O, Middleton N, Gavatha M, Lamnisos D, Priftis KN, Yiallouros PK. Asthma and atopy in children born by caesarean section: effect modification by family history of allergies - a population based cross-sectional study. BMC Pediatrics. 2012; 12:179-179. 7. Guise JM, Eden K, Emeis C, Denman MA, Marshall N, Fu RR, et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep). 2010; (191):1-397. 8. Dodd JM, Crowther CA, Huertas E, Guise JM, Horey D. Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews. 2013; Issue 12. Art. No.: CD004224. DOI:10.1002/14651858.CD004224.pub3. 9. Crowther CA, Dodd JM, Hiller JE, Haslam RR, Robinson JS. Planned vaginal birth or elective repeat caesarean: patient preference restricted cohort with nested randomised trial. PLoS Med. 2012; 9(3):e1001192. 10. Queensland Government. Queensland Perinatal Statistics 2012. 2013 [cited 2014 November 24]. Available from: http://www.health.qld.gov.au/hsu/peri/peri2012/report2012.asp. 11. New South Wales Kids and Families. Maternity – supporting women in their next birth after caesarean section (NBAC). GL2014_004. North Sydney: Ministry of Health, NSW; 2014. 12. Gardner K, Henry A, Thou S, Davis G, Miller T. Improving VBAC rates: the combined impact of two management strategies. Aust N Z J Obstet Gynaecol. 2014; 54(4):327-32. 13. Department of Health, Queensland Government. Clinical Services Capability Framework for Public and Licensed Private Health Facilities. [cited 2014 November 24]. Available from: http://www.health.qld.gov.au/cscf/default.asp. 14. SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 (Replaces guideline Number 147), February 2005. Int J Gynaecol Obstet. 2005; 89(3):319-31. 15. American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. Clinical management guidelines for obstetrician-gynecologists. Obstet Gynecol. 2010 (reaffirmed 2013); 116:450-63. 16. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Planned Vaginal Birth after Caesarean Section (Trial of Labour), C-Obs 38. 2010. Available from: http://www.ranzcog.edu.au. 17. National Institute of Health and Clinical Excellence. Caesarean section. NICE clinical guideline 132. London: National Institute of Health and Clinical Excellence; 2011. 18. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Categorisation of urgency for caesarean section. C-Obs 14. College Statement. 2012. 19. New South Wales Department of Health. Maternity – towards normal birth in NSW. A woman friendly birth initiative: protecting, promoting and supporting normal birth. Policy Directive. PD2010_045. 2010. 20. Queensland Government. Caesarean Birth Clinical Pathway. V7.00 -06/2012. Mat. No.: 10253035. 2012. 21. Callegari LS, Sterling LA, Zelek ST, Hawes SE, Reed SD. Interpregnancy body mass index change and success of term vaginal birth after cesarean delivery. Am J Obstet Gynecol. 2014; 210(4):330 e1-7. 22. Dietert RR. The microbiome in early life: self-completion and microbiota protection as health priorities. Birth Defects Research. Part B, Developmental And Reproductive Toxicology. 2014; 101(4):333-340. 23. Charles S. The ethics of vaginal birth after cesarean. Hastings Cent Rep. 2012; 42(4):24-7.

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) 24. American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010; 116(2 Pt 1):450-63. 25. Royal College of Obstetricians and Gynaecologists. Birth after previous caesarean birth. Guideline No.45. 2007. 26. Roberge S, Chaillet N, Boutin A, Moore L, Jastrow N, Brassard N, et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. International Journal of Gynaecology and Obstetrics. 2011; 115(1):5-10. 27. Hesselman S, Högberg U, Ekholm-Selling K, Råssjö EB, Jonsson M. The risk of uterine rupture is not increased with single- compared with double-layer closure: a Swedish cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2014; DOI: 10.1111/1471-0528.13015. 28. Roberge S, Bujold E. Closure of uterus and the risk of uterine rupture. BJOG: An International Journal of Obstetrics & Gynaecology. 2014; DOI:10.1111/1471-0528.13095. 29. Cunningham FG, Bangdiwala SI, Brown SS, Dean TM, Frederiksen M, Rowland Hogue CJ, et al. NIH consensus development conference draft statement on vaginal birth after cesarean: new insights. NIH Consens State Sci Statements. 2010; 27(3):1-42. 30. Kok N, Wiersma I, Opmeer B, De Graaf I, Mol B, Pajkrt E. Sonographic measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor in women with previous cesarean section: a meta-analysis. Ultrasound Obstet Gynecol. 2013; 42:132-9. 31. Penders J, Gerhold K, Thijs C, Zimmermann K, Wahn U, Lau S, et al. New insights into the hygiene hypothesis in allergic diseases: mediation of sibling and birth mode effects by the gut microbiota. Gut Microbes. 2014; 5(2):239-244. 32. Dekker GA, Chan A, Luke CG, Priest K, Riley M, Halliday J, et al. Risk of uterine rupture in Australian women attempting vaginal birth after one prior caesarean section: a retrospective population-based cohort study. BJOG. 2010; 117(11):1358-65. 33. Kok N, Ruiter L, Hof M, Ravelli A, Mol BW, Pajkrt E, et al. Risk of maternal and neonatal complications in subsequent pregnancy after planned caesarean section in a first birth, compared with emergency caesarean section: a nationwide comparative cohort study. BJOG. 2014; 121(2):216-23. 34. Tahseen S, Griffiths M. Vaginal birth after two caesarean sections (VBAC-2)-a systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. BJOG: An International Journal Of Obstetrics And Gynaecology. 2010; 117(1):5-19. 35. MIMS Online. Dinoprostone (Cervidil Pessary & Prostin E2 Vaginal Gel). 2014 [cited 2014 December 01]. Available from: http://www.mimsonline.com.au/. 36. MIMS Online. Syntocinon (Synthetic oxytocin). 2014 [cited 2014 December 01]. Available from: http://www.mimsonline.com.au/. 37. Queensland Clinical Guidelines. Normal birth. Guideline No. MN12.25-V1-R17. Queensland Health. 2012. Available from: www.health.qld.gov.au/qcg/. 38. Jauniaux E. Consent for vaginal birth after caesarean: changing horses in midstream. BJOG: An International Journal of Obstetrics & Gynaecology. 2014; 121(2):223. 39. Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for recognising and responding to clinical deterioration. Sydney: ACSQHC; 2010. 40. Queensland Clinical Guidelines. Intrapartum fetal surveillance. Guideline No. MN15.15-V4-R20. Queensland Health. 2015. Available from: www.health.qld.gov.au/qcg/. 41. Queensland Clinical Guidelines. Induction of labour. Guideline No. MN11.22-V4-R16. Queensland Health. 2011. Available from: www.health.qld.gov.au/qcg/. 42. Nahum GG. Uterine rupture in pregnancy. Medscape. 2015 [cited 2015 April 2]. Available from: http://reference.medscape.com. 43. Revicky V, Muralidhar A, Mukhopadhyay S, Mahmood T. A Case Series of Uterine Rupture: Lessons to be Learned for Future Clinical Practice. Journal of Obstetrics and Gynaecology of India. 2012; 62(6):665-673. 44. Institute for Clinical Systems Improvement. Management of labour: health care guideline. [online]. 2009 [cited 2009 July 7]. Available from: http://www.icsi.org/guidelines_and_more/gl_os_prot/womens_health/labor/labor__management_of__2.html. 45. Lenihan M, Krawczyk A, Canavan C. Shoulder-tip pain as an indicator of uterine rupture with a functioning epidural. Int J Obstet Anesth. 2012; 21(2):200-1.

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Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC)

Acknowledgements Queensland Clinical Guidelines gratefully acknowledge the contribution of Queensland clinicians and other stakeholders who participated throughout the guideline development process particularly: Working Party Clinical Lead Dr Inez Bardell, Visiting Medical Specialist, Obstetrics and Gynaecology, Royal Brisbane and Women’s Hospital and Ipswich Hospital Associate Professor Kassam Mahomed, Senior Staff Specialist, Obstetrics and Gynaecology, Ipswich Hospital and University of Queensland Working Party Members Mrs Kaye Amos-Fleming, Maternity Clinical Educator, Maternity and Women's Health Unit, Sunshine Coast Private Hospital Dr Fatima Ashrafi, Flying Obstetrician and Gynaecologist, South West Hospital and Health Service Mrs Anne Barnes, Midwife, Women and Birthing, Redland Hospital Dr Margaret Bickerstaff, Staff Specialist, Bundaberg Family Unit, Bundaberg Base Hospital Mrs Lisa Birmingham, Women's Health Physiotherapist, Royal Brisbane and Women’s Hospital Mrs Anne Bousfield, Midwifery Unit Manager, Roma Hospital Dr Anthony Brown, Medical Superintendent, Mareeba Hospital Ms Anne Clayton, Nursing and Midwifery Director, Caboolture Hospital Dr Lindsay Cochrane, Staff Specialist Obstetrics and Gynaecology, Caboolture Hospital Mrs Kelly Cooper, Midwife, Birth Suite, Royal Brisbane and Women’s Hospital; and Australian College of Midwives, Queensland Branch Executive Member Mrs Cara Cox, Clinical Midwife, Birth Suite, Royal Brisbane and Women’s Hospital Mrs Carole Dodd, Clinical Midwife, Maternity Unit, Caboolture Hospital Ms Anne Eaton, Midwifery Unit Manager, Proserpine Hospital Ms Kerri-Anne Gifford, Midwife, Ngarrama Midwifery Group Practice – Indigenous Maternity Service, Caboolture Hospital Dr Sarah Gleeson, Visiting Medical Officer, Advanced Practice (Obstetrics), Maternity Service, Goondiwindi Hospital Leah Hardiman, Rhianna Weekes, Alecia Staines, Bec Waqanikalou, Maternity Choices Australia Mrs Penny Hill, Midwife, RBWH Ms Louise Homan, Midwife/Nurse Unit Manager, Birth Suite, Cairns Hospital Ms Pauline Inverarity, Clinical Caseload Midwife, Midwifery Group Practice, Birth Centre, Gold Coast University Hospital Ms Kay Jones, Midwifery Lecturer/Researcher, School of Nursing and Midwifery, Griffith University Mrs Fiona Kajewski, Clinical Midwife Consultant, Maternity Services, Toowoomba Hospital Dr Nathan Kesteven, GP Obstetrician, Beaudesert Hospital Associate Professor Rebecca Kimble, Clinical Director, Obstetrics and Gynaecology, Royal Brisbane and Women’s Hospital Mrs Sarah Kirby, Midwifery Unit Manager, Birth Suite, Royal Brisbane and Women’s Hospital Associate Professor Thomas McHattie, Clinical Director, Obstetrics and Gynaecology, Wide Bay Hospital and Health Service Mrs Melanie McKenzie, Consumer Representative, High Risk Pregnancy and Bereavement, Director and Co-Founder, Harrison's Little Wings Inc. Dr Bruce Maybloom, Resident Medical Officer, Obstetrics and Gynaecology, Queensland Dr Rachel Reed, Lecturer and Private Practice Midwife, School of Nursing and Midwifery, University of the Sunshine Coast Mrs Pam Sepulveda, Clinical Midwife Consultant, Birth Suite, Logan Hospital Mrs Susan Simpson, Clinical Midwife, Birth Suite, Ipswich Hospital Dr Robyn Thompson, Midwife and Breastfeeding Consultant, Visiting Scholar, Mater Midwifery Research Unit Dr Jocelyn Toohill, Midwife Researcher/Lecturer, School of Nursing and Midwifery, Griffith University Mrs Bethan Townsend, Clinical Midwife, Midwifery Group Practice, Birth Centre, Gold Coast University Hospital Dr Clare Walker, Senior Medical Officer, Maternity Services, Longreach Hospital Mrs Lyn Wardlaw, Executive Director Nursing and Midwifery, Torres Strait and Cape York Hospital and Health Service Associate Professor Edward Weaver, Senior Medical Officer, Obstetrics and Gynaecology, Nambour General Hospital Mrs Kay Wilson, Nursing and Midwifery Director, Birthing and Ambulatory Services, Mater Mothers' Hospital Mrs Vanessa Wright, Clinical Midwife, Birth Suite, Logan Hospital Queensland Clinical Guidelines Team Associate Professor Rebecca Kimble, Director Ms Jacinta Lee, Manager Ms Lyndel Gray, Clinical Nurse Consultant Dr Brent Knack, Program Officer Ms Stephanie Sutherns, Clinical Nurse Consultant Steering Committee Funding This clinical guideline was funded by Queensland Health, Health Systems Innovation Branch.

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