VAGINAL BIRTH AFTER CAESAREAN SECTION

Vaginal Birth After Caesarean Section

Abstract

Around 10% of the obstetric population have experienced prior Caesarean delivery. This study provides a practical evidence-based approach to the antenatal and intrapartum management of such women. A gestation-specific strategy is suggested. Women with an uncomplicated pregnancy and single previous lower segment Caesarean delivery may be managed in shared community care following counselling by a consultant midwife. It is important to provide complete informed consent detailing the risks and benefits for the woman that are individualised to her circumstances. It is estimated that planned vaginal birth after Caesarean exposes the woman to an additional 0.% risk (or 1 in 400) for experiencing an adverse perinatal outcome (antepartum stillbirth, delivery-related perinatal death or hypoxic ischaemic encephalopathy) compared with opting for elective repeat Caesarean section (ERCS). It is likely that this risk is significantly reduced for women who opt for ERCS at the start of the 39th week; however, direct evidence to support this is lacking.

Table of Contents

Abstract2

CHAPTER I4

Introduction4

Aims and Objectives of the study4

Research Quesiton5

Content5

Study design5

Pilot study6

Sampling6

Data Collection7

Data Analysis7

Validity and reliability of Data7

Ethical issues8

Rational of the Study8

Limitations of data9

CHAPTER II10

Literature Review10

Prevalence of women with previous Caesarean birth10

Management11

Overview of antenatal care11

Consultant midwife and consultant obstetrician review13

Items to be discussed during antenatal counselling13

Review of the previous Caesarean delivery14

Suitability for VBAC14

Maternal and perinatal risks and benefits of VBAC compared with ERCS15

Variation in how health outcomes are valued when counselling on risk and benefits17

Her individualised likelihood of VBAC success17

The woman's future fertility wishes18

The woman's preference for mode of delivery19

Planning and conducting ERCS19

Localisation of the placenta19

Delivery at weeks, otherwise administer antenatal corticosteroids if delivery is before weeks20

Preoperative considerations20

Planned VBAC beyond weeks' gestation21

CHAPTER III23

Methods23

Statistical analysis26

CHAPTER IV27

Results27

CHAPTER V35

Conclusion35

References40

Appendix49

CHAPTER I

Introduction

This study is based on, and updates, the evidence presented in the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline 'Birth after previous Caesarean birth' (RCOG, February 2007). The definitions of terms used are detailed in Table 1. Attempted vaginal delivery for women with a single previous low transverse cesarean section is associated with a lower risk of complications both for mother and baby than elective repeat cesarean section is., 2 and 3 Professional bodies have made concerted attempts to increase the proportion of women undergoing vaginal birth after a previous cesarean delivery through the dissemination of practice guidelines. Committee on Obstetrics: Maternal and Fetal Medicine, Guidelines for vaginal delivery after a previous cesarean birth, : American College of Obstetricians and Gynecologists, Washington (DC) (1984). and 5 These initiatives have met with limited success. and 7 An Ontario study that evaluated practice patterns before and after distribution of guidelines found that dissemination alone had little effect on practice patterns. Another study focused on local clinical opinion leaders to promote vaginal birth after cesarean section and found this approach more effective than audit and feedback (Shiono, 1987, 696-700).

Aims and Objectives of the study

The primary objective of this randomized trial was to assess the effect of a prenatal education program on the proportion of women undergoing vaginal birth after a previous cesarean ...