Dr. Elioba J. Raimon

1. VAGINAL BIRTH AFTER
CAESAREAN SECTION
BY
DR. ELIOBA J RAIMON (REG. NO. 2020-04-03445)
DR. M’MEBWA M. LUC ( REG NO. 2021-04-04560)
RESIDENTS – OBSTETRICS & GYNECOLOGY
SUPERVISOR
DR. JOY

2. INTRODUCTION
There is increasing number of caesarean section world wide and this
pose Immediate maternal morbidity and Long term obstetric
consequences such as future risk of uterine rupture and Increased risk of
abnormal placentation
Approximately 21% of women worldwide deliver by cesarean Section (1
in 5 childbirths) WHO 2021
Management of the woman who has undergone a previous cesarean
delivery has been a controversial topic for more than 100 years. By the
beginning of the 20th century, cesarean delivery had become relatively
safe.

3. INTRODUCTION CONT’D
For many decades, a scarred uterus was believed by most to contraindicate
labor out of fear of uterine rupture
Vaginal birth after cesarean section is clinically safe for majority of women
who have had one prior lower segment cesarean section
Success rate for attempted VBAC lie at 60% to 80% , however this is higher
if the women has had a previous vaginal delivery [1]
Therefore; Counseling patients about vaginal birth after cesarean Section is
becoming increasingly important

4. MODE OF DELIVERY AFTER
PREVIOUS C/S
Previous
Cesarean
Trial of Labor
after Cesarean
Vaginal Birth
after Cesarean
Failed
TOLAC/Cesarean
Elective Repeat
Cesarean

5. TRIAL OF LABOUR AFTER CAESAREAN DELIVERY
(TOLAC)
Trial of labour after caesarean delivery (TOLAC) refers to a planned
attempt to deliver vaginally by a woman who has had a previous
caesarean delivery, regardless of the outcome.
This method provides women who desire a vaginal delivery the possibility
of achieving that goal—a vaginal birth after caesarean delivery (VBAC).
VBAC is associated with decreased maternal morbidity and a decreased
risk of complications in future pregnancies as well as a decrease in the
overall caesarean delivery rate

6. TRIAL OF LABOUR AFTER CAESAREAN
DELIVERY (TOLAC) CONT’D
VBAC is associated with fewer complications than elective
repeat caesarean delivery, whereas a failed TOLAC is associated
with more complications
Therefore, assessing the likelihood of VBAC as well as the
individual risks is important when determining who is an
appropriate candidate for TOLAC

7. SUCCESS RATES FOR A TRIAL OF
LABOUR AFTER CAESAREAN
The overall success rate for a population of women undergoing
TOLAC appears to be in the 60% to 80% range [1]
Although some data suggest this rate may be lower in
contemporary practice [1]

8. SUCCESS RATES FOR A TRIAL OF
LABOUR AFTER CAESAREAN

9. BENEFITS OF VBAC
Women who achieve VBAC avoid major abdominal surgery
Lower rates of haemorrhage
Lower rates of thromboembolism
Lower risk infection
Shorter recovery period than women who have an elective repeat
caesarean delivery
For those considering future pregnancies, VBAC may decrease the risk of
maternal consequences related to multiple caesarean deliveries e.g.
Hysterectomy
Bowel or bladder injury
Transfusion
Infection
Abnormal placentation such as placenta previa and placenta accreta

10. CANDIDATES FOR A TRIAL OF LABOUR
AFTER CAESAREAN
The optimal candidates for planned TOLAC are those women in whom the
balance of risks (i.e., as low as possible) and chances of success (i.e., as high
as possible) are acceptable to the patient and health care provider. [1]
ACOG criteria for identifying candidates for TOLAC
One or two previous low transverse caesarean deliveries
Clinically adequate pelvis
No other uterine scars or previous rupture
Physicians immediately available throughout active labour capable of monitoring
labour and performing an emergency caesarean delivery

11. CANDIDATES FOR A TRIAL OF LABOUR
AFTER CAESAREAN CONT’D
It should be noted that these criteria identify women who are likely to be
reasonable candidates and do not exclude women with any other clinical
situation from the option of TOLAC. [1]
For example, several studies indicate that it may be reasonable to offer a
TOLAC to women with Macrosomia, gestation beyond 40 weeks, previous
low vertical incision, unknown uterine scar type, and twin gestation [1]
Conversely, a TOLAC is contraindicated in women at high risk for uterine
rupture.
A TOLAC should not be attempted in the following circumstances:
Previous classical or T-shaped incision or extensive transfundal uterine surgery
Previous uterine rupture
Medical or obstetric complications that preclude vaginal delivery

12. PREDICTORS FOR VBAC SUCCESS OR
FAILURE
INCREASE THE LIKELIHOOD OF SUCCESSFUL VBAC
Previous successful VBAC
Previous vaginal delivery
Favourable cervix
Spontaneous labour
Non-recurrent indication for previous caesarean section (e.g. breech
presentation)
Maternal age <40 years
Adequate pelvis
Gestational age between 37-40 weeks

13. DECREASE THE LIKELIHOOD OF SUCCESSFUL VBAC
Recurring indication (CPD/failed
2nd stage)
Short maternal stature
Short Interpregnancy interval < 18
months
 No previous VBAC
Previous preterm C.S.
Advanced maternal age
Preeclampsia
Multiple prior caesarean section
Gestational age > 40 weeks
Estimated foetal weight > 4 kg
Previous postpartum wound
infection
Maternal obesity (BMI >30)
Diabetes mellitus
 Multiple gestation
 Induction of labour
Breech in current pregnancy
PREDICTORS FOR VBAC SUCCESS OR FAILURE
CONT’D

14. MATERNAL DEMOGRAPHICS
Race, age, BMI, and insurance status have all been demonstrated to be
associated with the success of TOLAC.
In a multicentre study of 14,529 term pregnancies in which TOLAC was
attempted, white women had a 78% success rate, compared with 70% in
non-white women. [2]
Obese women are more likely to fail a TOLAC, as are women older than 40
years.
Conflicting data exist with regard to payer status

15. PRIOR INDICATION FOR
CAESAREAN DELIVERY
Success rates for women whose first caesarean delivery was performed
for a nonrecurring indication (breech, non-reassuring foetal well-being) are
similar to vaginal delivery rates for nulliparous women.
Prior caesarean delivery for a breech presentation is associated with a
reported success rate of 89%. [2]
In contrast, prior caesarean delivery for cephalopelvic disproportion (CPD)
or failure to progress (FTP) has been associated with success rates that
range from 50% to 67%. [2]

16. PRIOR VAGINAL DELIVERY
Prior vaginal delivery, including prior VBAC, is one of the greatest
predictors for successful TOLAC.
In one series, women with a prior vaginal delivery had an 87% TOLAC
success rate, compared with a 61% success rate in women without a prior
vaginal delivery. [3]
Caughey and colleagues reported that for patients with a prior VBAC, the
success rate was 93%, compared with 85% in women with a vaginal
delivery before their caesarean birth but who had not had a successful
VBAC.

17. BIRTH WEIGHT
Increased birth weight is associated with a lower likelihood of a
successful VBAC.
Birth weight greater than 4000 g in particular is associated with a
higher risk for failed VBAC. [4]
It should be noted that although birth weight has been
associated with the success of VBAC, this factor cannot be known
with precision prior to undertaking TOLAC, and it has not been
demonstrated to what degree estimated foetal weight is
associated with VBAC.

18. LABOUR STATUS AND CERVICAL
EXAMINATIONS
Both labour status and cervical examination on admission influence the
success of a TOLAC.
Flamm and Geiger reported an 86% success rate in women who presented
in labour with cervical dilation greater than 4 cm. Conversely, the VBAC
success rate dropped to 67% if the cervix was dilated less than 4 cm on
admission. [5]
Not surprisingly, women who undergo induction of labour are at higher
risk for repeat caesarean delivery compared with those who enter
spontaneous labour.

19. PREVIOUS OR UNKNOWN
INCISION TYPE
Previous incision type cannot be ascertained in certain patients.
Nevertheless, it appears that women whose previous incision
type is unknown have VBAC success rates similar to those of
women with documented prior low transverse incisions.
Similarly, women with previous low vertical incisions do not
appear to have lower VBAC success rates.

20. MULTIPLE PRIOR CAESAREAN
DELIVERIES
Women with more than one prior caesarean delivery have been
demonstrated to have a lower likelihood of achieving VBAC
Caughey and colleagues reported a 75% success rate for women
with one prior caesarean delivery compared with 62% in women
with two prior operations.

21. POST TERM PREGNANCY
TOLAC success rates may be lower for women at or beyond 40
weeks of gestation when compared with those who have yet to
reach 40 weeks.
Nevertheless, the chance of success for women who are at or
beyond 40 weeks of gestation has been demonstrated to be
approximately 70%, and a gestational age beyond a woman’s due
date should not preclude TOLAC. [6]

22. TWIN GESTATION
Two large-scale contemporary studies 9,16 of women
attempting VBAC indicate that success rates for women
undergoing TOLAC with twins are not different than for those
with singleton gestations. [7]

23. RISKS ASSOCIATED WITH A TRIAL OF
LABOR AFTER CESAREAN
Uterine Rupture
The principal risk associated with TOLAC is uterine rupture.
It is important to differentiate between uterine rupture and uterine
scar dehiscence.
uterine dehiscence, the serosa of the uterus is intact and
haemorrhage, with its potential for foetal and maternal sequelae, is
absent.
uterine rupture is the disruption of all uterine layers, with potential
consequences of nonreassuring foetal status and perinatal mortality
along with severe maternal morbidity, haemorrhage, and mortality

24. RISK FACTORS FOR UTERINE RUPTURE
Rates of uterine rupture vary significantly depending on a
variety of associated risk factors which includes.
Type and location of uterine scar
Number of prior caesarean
Vaginal deliveries
The interdelivery interval
Uterine closure technique
Induction of labour
Use of oxytocin augmentation

25. RISK OF SCAR RUPTURE

26. Previous classical or inverted T-shaped
or J- shaped uterine incision
Previous uterine surgery
(myomectomy) or prior low vertical
incision
Two prior uterine scars with no vaginal
delivery
Previous extensive transfundal uterine
surgery
Previous history of uterine rupture
Contracted pelvis
Medical or obstetric complications
that precludes vaginal birth:
Placenta previa
Elderly patient
Long standing 2o infertility
Previous perinatal deaths
Inability to perform emergency LSCS
Previous significant sepsis post
caesarean section.
Inability of health care facility to
perform emergency caesarean section
CONTRAINDICATIONS TO VBAC

27. COUNSELLING OF A WOMAN FOR
DELIVERY MODE
Trial of labour after caesarean section
1 in 200 risk of scar rupture
Risk of hypoxic ischemic
encephalopathy to the new born
(About 8/10,000 deliveries)
Elective Repeat caesarean section
Increased risk of placenta previa
and accreta in future
pregnancies
Small increased risk of transient
neonatal respiratory morbidity

28. ANTENATAL MANAGEMENT IN WOMEN
ATTEMPTING TRIAL OF LABOUR (TOLAC)
It is a high risk pregnancy, requiring special ANCs
Obtain records or information regarding previous caesarean, its indication,
previous uterine scar
Correct dating of pregnancy is essential, from
• History
• Clinical examination
• USG
Early detection of other obstetric (esp. placenta previa, PIH etc.) and
medical complications (anaemia etc.).
All routine investigations to be done

29. ANTENATAL MANAGEMENT IN WOMEN ATTEMPTING
TRIAL OF LABOUR (TOLAC) CONT’D
If VBAC is to be considered, rule out the following:
Malpresentation
Multiple pregnancy
Macrosomia
In 3rd trimester: at every visit, enquire about:
Foetal movements
Suprapubic pain
Palpate for scar tenderness
Vaginal bleeding

30. ANTENATAL MANAGEMENT IN WOMEN
ATTEMPTING TRIAL OF LABOUR (TOLAC) CONT’D
Ultrasound:
Foetal maturity especially when LMP is not certain
Foetal weight
Placental localization
Scar integrity assessment
Why is it necessary to know placental location in a case of previous LSCS?
Placental localization over the site of previous scar is one of the
major causes making the scar weak resulting in uterine rupture
If placenta is low lying and anterior → placenta accreta should be
sought on USG with colour Doppler
Trial of labour → not indicated in these patients.

31. ANTENATAL MANAGEMENT IN WOMEN ATTEMPTING
TRIAL OF LABOUR (TOLAC) CONT’D
For TOL → pelvic assessment at 37 weeks and again in early labour
Proper counselling for risks and benefits
Patients staying far → admit at 38 weeks
Spontaneous labour has high success rates
Trial of labour, should not be attempted if haemoglobin is ≤ 9 g/dl or blood
is not arranged (correction of anaemia is very important)

32. ANTENATAL MANAGEMENT IN WOMEN ATTEMPTING
TRIAL OF LABOUR (TOLAC) CONT’D
Induction of labour (IOL) → not a contraindication but the risks should be
explained:
Risk of uterine rupture is increased 2-3 fold
Likelihood of repeat caesarean section with IOL -1.5 fold
Misoprostol should NOT be used in 3rd trimester for cervical ripening or
labour induction in cases of previous LSCS
Proper counselling and consent for sterilization (if appropriate at that time).
Written and informed consent (all risks and benefits)

33. EXPLAIN ALL RISKS AND BENEFITS WHILE OBTAINING
INFORMED CONSENT FOR TOLAC
RISK
Uterine rupture, shock, hysterectomy
Need for blood transfusion
Operative delivery →↑ chances of
surgical injury
Increased foetal morbidity and in few
cases mortality
Increased rate of admission to NICU
Long separation of mother and baby
Delayed resumption of breastfeeding
Risk of postoperative infection
Longer hospital stay
BENEFITS
Overall success rates are high
Shorter hospital stay
Less postpartum pain
Less postpartum infections
Fewer chances of blood transfusions
Early initiation of breastfeeding
Reduced chances of respiratory
problems requiring admission to
NICU
Less chances of placenta previa
accreta in subsequent pregnancy.

34. MANAGEMENT IN LABOR
Delivery → always where facility for emergency caesarean
section is present.
1st stage of labour
Blood group and cross match should be done
Patient kept NPO or on a liquid diet
IV line secured
Anaesthetist and neonatologist kept informed

35. MANAGEMENT IN LABOR CONT’D
Monitoring done meticulously:
FHS
If facilities available → CTG
If not, intermittent auscultation or use of Doppler
Partograph – for progress of labour (PR, BP, FHS, contractions and scar
tenderness)
Oxytocin – can be used for augmentation but judiciously. Once good
uterine contractions start, cervical dilatation should be minimum 1 cm/hour
Amniotomy can be performed once cervix is 3-4 cm dilated
Slow IV fluids started (avoid dehydration)
Epidural analgesia is not contraindicated in VBAC

36. MANAGEMENT IN LABOR CONT’D
Watch for symptoms and signs of scar dehiscence and impending rupture
SYMPTOMS
Suprapubic pain persisting in between contractions and aggravated
during contractions
Slight fresh vaginal bleeding
Loss of station of presenting part
Changes in uterine contour
Development of in coordinate uterine action in active labour and
complete cessation of contractions
There can be development of frank haematuria

37. MANAGEMENT IN LABOR CONT’D
Watch for symptoms and signs of scar dehiscence and impending rupture
cont’d.
SIGNS
Non reassuring FHR pattern → 1st sign of uterine rupture
• FETAL BRADY CARDIA → most consistent finding
• Others – prolonged and variable decelerations
Scar tenderness (suprapubic pain and tenderness)
Unexplained tachycardia
Hypotension
Sudden onset of shortness of breath
Suprapubic bulge
Rarely, chest pain or shoulder tip pain

38. MANAGEMENT IN LABOR CONT’D
2nd Stage
Should not be prolonged
Bladder should be emptied
Patient should be allowed to bear down on her own (NO FUNDAL
PRESSURE)
Episiotomy to cut short 2nd stage
Vacuum and outlet forceps application is not a contraindication in VBAC,
but used with caution.
3rd Stage
Exploration of the uterine scar is not warranted unless there is post
partum haemorrhage which fails to settle with appropriate medication

39. REFERENCE
1. ACOG Practice Bulletin No. 115: Vaginal birth after previous caesarean
delivery. Washington, DC: American College of Obstetricians and
Gynaecologists; 2010.
2. Landon MB, Leindecker S, Spong CY, et al. The MFMU Caesarean Registry:
factors affecting the success and trial of labour following prior caesarean
delivery. Am J Obstet Gynecol. 2005;193:1016.
3. Caughey AB, Shipp TD, Repke JT, et al. Trial of labor after caesarean
delivery: the effects of previous vaginal delivery. Am J Obstet Gynecol.
1998;179: 938.
4. Wing DA, Lovett K, Paul RH. Disruption of prior uterine incision following
misoprostol for labor induction in women with previous cesarean delivery.
Obstet Gynecol. 1998;91:828.

40. 5. Flamm BL, Geiger AM. Vaginal birth after caesarean delivery: an admission
scoring system. Obstet Gynecol. 1997;90:907.
6. Coassolo KM, Stamilio DM, Paré E, et al. Safety and efficacy of vaginal birth
after caesarean attempts at or beyond 40 weeks of gestation. Obstet Gynecol.
2005;106:700-706
7. Macones G, Peipert J, Nelson D, et al. Maternal complications with vaginal
birth after caesarean delivery: a multicenter study. Am J Obstet Gynecol.
2005;193:1656.
8. Williams textbook of Obstetrics, 25th edition
9. Obstetrics normal and problem pregnancy by Gabbe et al
10. DC Dutta’s textbook of Obstetric
REFERENCE

41. THE END
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