Vaginal birth after cesarean section (VBAC) is the term applied to women who undergo vaginal delivery following cesarean delivery in a prior pregnancy. Patients desiring VBAC delivery undergo a trial of labor (TOL) or trial of labor after cesarean section (TOLAC).

1. B
A baby is something you carry inside you for nine months, in your
arms for three years, and in your heart until the day you die. You'll
be his/her first kiss, his first love, his first friend. You are his mum
and he is your whole world.

2. STAFF DEVELOPMENT
PROGRAME
ON
VAGINAL BIRTH AFTER A
CESAREAN SECTION
PRESENTED BY,
MRS. PRIYA PAUL
ASSOCIATE PROFESSOR
KNPI, LUCKNOW

3. ▪ INTRODUCTION
▪ BACKGROUND
▪ DEFINITION
▪ OPTIONS FOR A PATIENTS WITH PREVIOUS CS
▪ WHICH WOMEN ARE BEST SUITED TO HAVE A PLANNED VBAC
▪ SELECTION OF A CANDIDATE FOR VBAC
▪ IMPORTANCE OF BISHOP SCORE
▪ CRITERIA FOR SUCCESS
▪ RISK AND BENEFITS
▪ CONTRAINDICATION
▪ DETERMINING THE MODE OF DELIVERY
▪ IMPORTANT THINGS TO BE CONSIDERED
▪ PLANNING AND CONDUCTING ERCS
▪ SUCCESS RATE IN INDIA
▪ ACOG GUIDELINES
▪ CURRENT RESEARCH STUDIES
▪ CONCLUSION
▪ REFERENCES
CONTENT

4. INTRODUCTION
Many women who have had a caesarean section can
safely have a vaginal delivery for their next baby,
known as Vaginal Birth After a Caesarean (VBAC). It is
said that “once a caesarean, always a caesarean”. It is
commonly believed that a woman who has undergone a
c-section delivery will have to opt for the same method
while giving birth to her next child. But medical experts
are trying to dispel this myth.

5. According to Dr Mukta Kapila, Director, Obstetrics and
Gynecology, at Fortis Gurgaon. “Any woman with a
previous caesarean section can attempt a VBAC. The
majority of women, despite having a C-section delivery,
often prefer a vaginal delivery. Women are showing
more courage towards this. It is safe and the established
hospitals are providing full support to mothers who plan
to go for a vaginal delivery,”

6. BACKGROUND

7. ⦁ Cragin himself witnessed VBAC in a woman in
whom he did the caesarean
⦁ Rethinking the Dictum : Case in 1930s gave an
excellent review on VBAC showing 70% success
rate in British Population
⦁ In U.S., till 1970, patients with previous cesarean
were mostly delivered by elective repeat cesarean –
leading to Five-fold increase in rate of cesarean
deliveries
⦁ From 1980 onwards, re-appraisal of the situation,
careful selection of candidates for VBAC began
⦁ First guideline was formed by ACOG in 1999

8. A C-section (or cesarean birth) is a surgical procedure used to
deliver a baby when a vaginal delivery can't be done safely. A
C-section can be planned ahead of time or performed in an
emergency. It carries more risk than a vaginal delivery, with a
slightly longer recovery period. Dr Rinku Sengupta, who had
been associated with the Sitaram Bhartia Institute of Science and
Research , New Delhi, as Maternity Programme, Head, said that
in recent times two out of three women with a previous c-section
deliveries attempt a VBAC and almost 90 per cent of them are
successful.

9. DEFINITION
VBAC (Vaginal Delivery After a Cesarean Section)
refers to a vaginal delivery in a women who has given
birth via cesarean section in a former pregnancy.

10. OPTIONS FOR A PATIENT
• Elective repeat cesarean Delivery
(ERCD) – Also called ERCS
(Elective Repeat Cesarean
Section)
• Trial of labor after cesarean (TOLAC)
This can have 2 outcomes
▪ Successful TOLAC – Vaginal
Birth After Cesarean Delivery
▪ Failed TOLAC -Emergency
cesarean Delivery
WITH PREVIOUS CESAREAN

11. WHICH WOMEN ARE BEST SUITED TO
HAVE A PLANNED VBAC?
Planned VBAC is appropriate for and may be offered to
the majority of women with a singleton pregnancy of
cephalic presentation at 37+ weeks or beyond who have
had a single previous lower segment caesarean delivery,
with or without a history of previous vaginal birth.

12. SELECTION OF CANDIDATES
FOR VBAC
• Clinically adequate pelvis
• One previous prior low-transverse cesarean delivery
• No other uterine scar / previous rupture
• Obstetrician and physician immediately available throughout
active labor, capable of monitoring labor, performing an
emergency cesarean delivery
• Availability of anesthesia & other personnel for emergency
cesarean
delivery

13. Bishop score of 8 or greater is considered to be
favorable for induction, or the chance of a vaginal
delivery with induction is similar to spontaneous labor.
A score of 6 or less is considered to be unfavorable if an
induction is indicated cervical ripening agents may be
utilized.
IMPORTANCE OF BISHOP SCORE

14. ⦁ Factors increasing likelihood of success
▪Maternal age < 40
▪Favorable cervix, spontaneous labor
▪Prior cesarean for non recurrent indication
⦁ Factors decreasing likelihood of success
▪Increased number of prior cesarean
deliveries
▪Gestational age > 40 weeks
▪Birth weight > 4 kg
▪Induction or augmentation of labor
▪Dystocia, CPD

16. Vaginal birth after caesarean section Emergency caesarean delivery
72- 76% chance of success Able to plan the delivery on a known
date
If successful, shorter hospital stay Lower risk of vaginal tears &no
worsening of pelvic floor support.
Increased likelihood of vaginal delivery
in future pregnancies
Surgical sterilization can be done at the
same time
Lower risk of transfusion (1%) &
endometritis (1.8%) as compared to
failed TOLAC

17. VBAC ERCD
10-15% chance of instrumental delivery
& perineal tear requiring suturing
Increases likelihood of cesarean delivery
in future pregnancy
Failed TOLAC increases maternal
morbidity
Longer hospital stay
0.5% of risk of uterine scar rupture –
most dreaded complication
0.1- 2% chances of serious surgical
complications like bladder injury
24-28% of chance of emergency cesarean
delivery
Increased risk of surgical complications
with each subsequent cesarean delivery
due to adhesions, placenta
praevia/accreta
Higher risk of blood transfusion(1.7%) &
endometritis(2%)

18. VBAC ERCD
<1% risk of transient respiratory
morbidity (<ERCD)
Avoids 0.1% risk of antepartum still
birth since delivery is undertaken at
the commencement of 39th week

19. VBAC ERCD
0.1% risk of antepartum still birth
beyond 39 wks while awaiting
spontaneous labor
1-3% risk of transient respiratory
morbidity
0.04% risk of delivery related
perinatal death
0.08% of HIE (Hypoxic ischaemic
encephalopathy) during labor

20. CONTRAINDICATION TO TOLAC
• Previous uterine rupture
• Previous high vertical, classical, T shaped cesarean section
• 3 or more previous cesarean deliveries.
• Contracted pelvis/Cephalo Pelvic Disproportion
• Obstetric or Medical complication
• Malpresentation,APH, Severe PIH, Eclampsia, Placental
insufficiency
• Medical disorders like Hypertension , Heart disease,
Renal disease,Asthma, Seizure disorders
• Inability to perform emergency cesarean due to insufficient
staffing / facilities
• Where the women herself refuses.

21. -Review previous
medical records &
operative notes,
- Assess risks & benefits

22. IMPORTANT THINGS TO
BE CONSIDERED

23. ANTENATAL COUNSELING
• Women with a prior history of one uncomplicated LSCS , in an
otherwise uncomplicated pregnancy at term, with no
contraindication to vaginal birth, should be able to discuss the
option of planned VBAC and the alternative on an elective repeat
cesarean
• The antenatal counseling of women with a prior cesarean birth
should be documented in the notes.
• A final decision for mode of birth should be agreed between the
woman and her obstetrician before the expected/planned delivery
date, ideally by 36weeks of gestation.

24. INTRAPARTUM MANAGEMENT
• Women who have had a previous cesarean section should be
offered care during labour in a unit where:
• There is immediate access to cesarean section.
• There are on site blood transfusion services or blood can be
obtained with in a reasonable amount of time.
• Facilities for continuous fetal heart monitoring are available,
preferably electronic fetal heart monitoring.
• Specialist obstetricians, anesthetists and pediatrician are available
round the clock.

25. ⦁ Take detailed informed written consent
⦁ To be conducted in a suitably staffed & equipped setting
with the facility for emergency cesarean delivery 24x7 &
neonatal resuscitation
⦁ Prostaglandin may be used to induce labor with caution.
⦁ IV access, adequate blood cross matched
⦁ Monitor maternal Vitals every 15 min

26. ⦁ Oxytocin should be used with caution (In AIIMS - low
dose, starting from 1mIU/min is being used for
augmentation)
⦁ No contraindication for epidural analgesia – does not
reduce success or mask signs of rupture
⦁ Regular review of partogram by senior obstetrician

27. CONTINUOUS FETAL MONITORING
• Continuous electronic fetal monitoring is recommended
following the onset of uterine contractions for the duration of
TOLAC
• An abnormal CTG is the most consistent finding in uterine
rupture and is present in 55% to 87% of these events(guise et
al 2004)

28. PARTOGRAM FOR PROGRESS
OF LABOUR
• A partogram, in addition to monitoring progress of labour , enables
effective monitoring of maternal parameters like blood pressure and
pulse rate.
• The duration of labour should be closely monitored with special
reference to alert and action line on partogram. Prolongation of
labour is an important sign of dystocia.

29. ANALGESIA
• Epidural analgesia for labour may be used as part of TOLAC ,
and adequate pain relief may encourage women to choose
TOLAC.

30. DELIVERY
• second stage should not exceed 2 hrs. 1 hour to allow passive
descent, but no more than 1 hour for active pushing (or 30 minutes
if the woman has had a prior vaginal delivery)
• Assisted delivery, should ideally only be performed by an
experienced consultant. This should be in the operating theatre
with provision for immediate cesarean section
• Excessive vaginal bleeding or signs of hypovolemia are potential
signs of uterine rupture and should prompt complete evaluation of
the genital tract.

31. COMPLICATION

32. • Most Dreaded complication of TOLAC
• Risk of uterine rupture in TOL 0.5%
• Maternal and or fetal morbidity of rupture 10-25%
• In rupture, 1.5/10,000 risk of perinatal death & 4.8/10,000
risk of hysterectomy
• Early diagnosis of uterine scar rupture followed by
expeditious laparotomy and resuscitations essential to
reduce associated morbidity and mortality and infants.
UTERINE RUPTURE

33. • Uterine rupture – Complete disruption of all layers of uterus
associated with one/more of the following-
▪Hemorrhage requiring surgical exploration
▪Hysterectomy, Injury to the bladder
▪Extrusion of any part of feto-placental unit
▪Cesarean delivery for suspected uterine rupture, fetal distress
• Uterine dehiscence –Asymptomatic uterine disruption (complete
or incomplete) having no effect on mother or neonate
UTERINE RUPTURE
V/S
UTERINE DEHISCENCE

34. CLINICAL FEATURES ASSOCIATED WITH
UTERINE SCAR RUPTURE
• Abnormal CTG
• Severe abdominal pain, especially if persisting between contractions
• Acute onset scar tenderness
• Abnormal vaginal bleeding
• Hematuria
• Cessation of previously efficient uterine activity
• Maternal tachycardia, hypotension, fainting or shock
• Loss of station of the presenting part
• Change in abdominal contour and inability to pick up fetal heart rate
at the previous site.
UTERINE SCAR RUPTURE
• Abnormal CTG
• Severe abdominal pain, especially if persisting between contractions
• Acute onset scar tenderness
• Abnormal vaginal bleeding
• Hematuria
• Cessation of previously efficient uterine activity
• Maternal tachycardia, hypotension, fainting or shock
• Loss of station of the presenting part
• Change in abdominal contour and inability to pick up fetal heart rate
at the previous site.

35. PLANNING AND CONDUCTING ERCS
ERCS delivery should be conducted after
39+0 weeks of gestation.

36. SUCCESS RATE IN INDIA
According to National Institute of Health, Approximately 90%
of the women who have undergone cesarean deliveries are
possible candidates for VBAC during their next pregnancy. And
60% - 80% among them are able to have successful vaginal
deliveries.
Track record of conducting highest successful VBACs in India is
testimony to the fact that with skilled care along with empathetic
care providers 95% of women who had previous C-Section can
have a VBAC. 29-Mar-2023

37. ACOG Guidelines
⦁ Most women with previous 1 LSCS are candidates
for VBAC & Should be counseled about VBAC &
offered TOLAC
⦁ Epidural analgesia for labor may be used as part of
TOLAC
⦁ Misoprostol should not be used for 3rd trimester
cervical ripening or labor induction in patients with
previous cesarean delivery or major uterine surgeries
ACOG practice bulletin
Level A Evidence

38. ⦁ VBAC is recommended in previous 2 LSCS with low
transverse scar and previous 1 LSCS with twins
⦁ ECV for breech is not contraindicated in previous LSCS
⦁ Scars other than low transverse/ low vertical scars or those in
whom vaginal delivery is contraindicated (eg. Placenta
accreta ) are contraindicated for VBAC.
⦁ Previous unknown uterine scar is not a contraindication unless
there is high suspicion of classical cesarean delivery
ACOG practice bulletin

39. RESEARCH STUDIES
Neha Varun et al (2023), conducted a prospective observational study
Vaginal birth after cesarean score for the prediction of successful vaginal birth after cesarean section,
The aim of this study was to evaluate the demographic and obstetrical factors affecting the chances of
vaginal birth after cesarean (VBAC) delivery and to develop a scoring system for the prediction of
same. Study done over a period of 1 year. A total of 100 term pregnant women with previous one
lower-segment cesarean section (LSCS) fulfilling the criteria for a trial of labor were recruited for the
study. As 23 patients refused to undergo trial of labor after cesarean (TOLAC) in early labor, 77
women formed the study group. Parameters assessed to predict successful TOLAC were maternal age,
body mass index (BMI), history of prior vaginal delivery, interdelivery interval, indication of previous
cesarean section, gestational age, type of labor, Bishop's score, and expected baby weight. Scores 0–2
were given, and the mean score obtained was correlated with the outcome of TOLAC. Result of the
study was, successful vaginal delivery occurred in 57.14% (44/77) of women. BMI ≤30 kg/m2 (P =
0.004), parity ≤ 3 (P = 0.005), Bishop's score >4 (P = 0.000), spontaneous onset of labor at the time of
admission (P = 0.001), and nonrecurrent indication of previous LSCS (P = 0.029) were found to be
significantly associated with the VBAC. The probability of having a successful VBAC was 83.3% and
100%, with the VBAC score value of more than 18 and 20, respectively. The study concluded that the
mean VBAC score of 18–20 by the current scoring system is beneficial in predicting the outcome.
This can help in counseling the patient, relatives as well as health professionals to undergo labor trial
to decrease the cesarean section rate in the current era.

40. Samar A Mohamed et al (2019), Conducted a Incidence and outcome of vaginal birth after
cesarean among women receiving counseling at El Manial University Hospital. The aim of
study was to examine the effect of counseling on the incidence, maternal, and neonatal
outcomes of VBAC. A quasi-experimental one-group post-test-only design was adopted for
this study. The study was conducted at the Outpatient Department at Researcher adopted a
purposive sampling technique to collect the sample of pregnant women through a period of 6
months from July to December 2019 based on certain criteria; the most important one is to
have a previous CS. Tool was used structured interviewing tool, labor progress record
(Partograph) Result of the study was a total of 90 participants were enrolled into study. A
total of 79 (87.8%) women agreed to have VBAC after counseling compared with only 11
(12.2%), who refused to have VBAC and chose CS. The trial of labor after cesarean
(TOLAC) rate was 40.5%. The rate of VBAC was 31.6%. Success rate of TOLAC was
78.1%, whereas failed TOLAC was 21.9% owing to lack of labor progress and fetal distress.
Overall, 68.4% had CSs lower segment cesarean section (LSCS). Among them, 37% had
elective LSCS and 63% had emergency LSCS. Physician decision without any medical
indication for CS was the most common indications of elective repeat CS, with a rate of
85%. Oligohydramnios was the most common cause for emergency CS delivery, with a rate
of 44.5%. All women who delivered VBAC had normal progress of labor and their babies
had normal Apgar score (8–10). Conclusion of the study was Counseling is needed for the
selection of VBAC as a mode of delivery. Successful VBAC is associated with better
fetomaternal and neonatal outcomes, so most women with one previous cesarean delivery
with a low-transverse incision should be counseled and encouraged to undergo a trial of
labor in her recurrent Pregnancy.

41. CONCLUSION
There is a consensus (National Institute for Health and Care
Excellence [NICE], Royal College of Obstetricians and
Gynaecologists [RCOG], American College of Obstetricians and
Gynecologists [ACOG]/ National Institutes of Health [NIH], that
planned VBAC is a clinically safe choice for the majority of women
with a single previous lower segment caesarean delivery. Such a
strategy will at least limit any escalation of the caesarean delivery
rate and maternal morbidity associated with multiple caesarean

42. REFERENCES
• RCOG Birth After Previous Caesarean Birth, Green-top
Guideline No. 45 ,October 2021
• Vaginal birth After Cesarean Delivery In: The management of labor, 3rd
edition, India Universities Press.
• Varun N, Nigam A, Gupta N, Mazhari F, Kashyap V. Vaginal birth after
cesarean score for the prediction of successful vaginal birth after cesarean
section – A prospective observational study. Indian J Med Spec [serial online]
2023 Available from: http://www.ijms.in/text.asp?2023/14/1/15/360049
• Mohamed SA, Elsayed YA, Ghonemy GE, Sharaf MF. Incidence and outcome
of vaginal birth after cesarean among women receiving counseling at El
Manial University Hospital. Egypt,Available
from: http://www.enj.eg.net/text.asp?2020/17/2/107/320267

43. THANK YOU