VBAC vs. Repeat Cesarean Policy

Contributor: Shelley Chapman, MD
Last Update: 9/4/2012

• The patient with a prior cesarean delivery should be given the ACOG pamphlet entitled  “Vaginal Birth After Cesarean Delivery” by her 20th week of gestation.   She should be  encouraged to read it and collect any questions she has.  She should have a return  appointment in the early third trimester to discuss planning delivery mode.
• The patient will receive nondirective counseling after review of the  operative and perinatal  record.  In the absence of a contraindication, VBAC will be  encouraged.  The risks and benefits of each choice should be adequately conveyed.

A risk assessment using the tool at www.perinatology.com under “calculators” and the “chance for successful VBAC” should be reviewed with the patient and the percentage for success noted in the patient’s OB record.

• The patient will sign a consent in which her desire is made clear.  She should understand  that she may change her choice later if desired.
• The patient will be reminded that if she presents in labor prior to an intended repeat  cesarean, she  will be evaluated and we will re-discuss options.
• Physicians scheduling a repeat cesarean should be certain the patient meets ACOG criteria  for at least 39 weeks or is scheduled for amniocentesis for FLM prior to cesarean .

Candidates for Trial of Labor 
The following are patients that are routinely offered a trial of labor following previous cesarean section.

• One previous low-transverse cesarean delivery
• Clinically adequate pelvis
• No other uterine scars or previous rupture
• Physician immediately available throughout active labor capable of monitoring labor and performing an emergent cesarean delivery
• Availability of anesthesia and personnel for emergent cesarean delivery

The following patients can be offered a trial of labor in certain circumstances.

• Women with 2 previous low transverse cesarean deliveries
• Suspected fetal macrosomia (4,000-4,500g)
• Unknown uterine scar – can offer based on clinical judgment and presumed uterine scar based on previous indication.
• Twin gestations in women with one prior cesarean that are otherwise appropriate candidates for VBAC.

Contraindications for Trial of Labor 
Patients at high risk of uterine rupture are not to be offered a trial of labor.

• Previous classical or T shaped uterine incision or extensive transfundal uterine surgery
• Previous uterine rupture
• Medical or obstetric complications that preclude vaginal delivery
• Inability to perform emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff, or facility

Management of Patients Undergoing a Trial of Labor
Induction of labor for maternal or fetal indications remains an option in women undergoing trial of labor after cesarean.

• No prostaglandins for cervical ripening will be administered.
• Patient must meet above criteria to be a considered an acceptable candidate.
• Patient should have IUPC and FSE placed to ensure accurate, continuous monitoring in active labor.
• Patient may have epidural for pain management per routine practice
• Observe patient for spontaneous cervical change. Decision to start oxytocin administration should only be considered in cases of inadequate labor progression. This decision should be discussed with the attending physician before oxytocin is initiated.
• No need to manually explore the uterus following delivery. There are no data to suggest this is beneficial.

Recommended Reading

ACOG Practice Bulletin 115, August 2010.  Vaginal Birth After Previous Cesarean Delivery