NOTES FOR UNDERGRADUATES AND POSTGRADUATES IN GYNE

1. DR.PRIYA SAXENA
VAGINAL BIRTH AFTER
CESAREAN(VBAC)

2. CURRENT RECOMMENDATIONS FOR
TOLAC AND VBAC
 Only one previous low segment transverse cesarean delivery. VBAC can also
be allowed in women with previous 2 LSCS with a vaginal delivery after
counselling
 Clinically pelvis should be adequate on clinical examination
 No other uterine scar (eg.hysterotomy) should be there
 No previous uterine rupture should be there
 Facilities for anesthesia and cesarean for emergency cesarean delivery should
be there
 Availability of round the clock obstetrician for monitoring of women in labor
and for performing emergency delivery
 Proper counseling of women about advantages, disadvantages and
contraindications of vaginal delivery, risk of uterine rupture, perinatal mortality
and neonatal neurological injury should be done.

3. CONTRAINDICATIONS FOR VBAC
 Previous classical incision
 Previous inverted T incision or extension of uterine incision
 Suspicion of CPD or contracted pelvis
 Previous 2 LSCS without a vaginal delivery
 Malpresentations
 Medical or obstetric complications
 Patient’s refusal to undergo trial of labor
 Previous uterine surgeries

4. MONITORING
 Trial of labor should only be conducted in a well equipped hospital with all
facilities for doing an emergency cesarean section.
 Proper counselling of women is a must in explaining them advantages of
vaginal delivery, contraindications of labor, risk of uterine rupture and risk of
fetal death and fetal neurological injury with uterine rupture
 Ideally spontaneous onset of labor is awaited.
 An intravenous line should be set up
 Crossmatched blood should be kept ready
 Maternal blood pressure and pulse should be recorded half hourly before the
active phase has begun and then every 15 minutes in active phase
 Labor monitoring for scar dehiscence and for fetal surveillance is performed
 Epidural analgesia is not contraindicated in a planned VBAC

5.  Induction of labor using mechanical methods is associated with a lower risk of
scar rupture compared with induction using prostaglandins
 Oxytocin is allowed for augmentation of labor
 Prostaglandins are used with caution. Prostaglandin E2 gel can be used but
PGE1 should be avoided due to risk of uterine rupture
 The pediatrician should be available at the time of delivery
 Any demonstration of hyperactivity of uterus or abnormality of fetal heart
sound on cardiotocography must alert the obstetrician .If in this case the cervix
is not fully dilated, a cesarean section should be performed immediately(within
30 minutes)
 Some authors measure intrauterine pressure by monitoring with a catheter. Any
loss of intrauterine pressure is an indication of uterine rupture and immediate
laparotomy is indicated. Forceps or ventouse to cut short the second stage of
labor can be used but not always required.

6.  Intrauterine exploration of the uterine scar after vaginal delivery is not
routinely performed nor indicated. However if there is active bleeding
,laparotomy is advised

7. RISKS OF VBAC
 Unsuccessful
 Risk of scar dehiscence and rupture
 Maternal morbidity and mortality is not usually increased, but there is slightly
more morbidity with scar rupture
 Perinatal morbidity and mortality is increased if there is scar rupture. There is
risk of fetal death and severe neurological injury including hypoxic ischemic
encephalopathy in uterine rupture.

8. THANK YOU