Health Care Guideline:
Vaginal Birth After Cesarean

Copyright © 1998 by Institute for Clinical Systems Integration

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Contents

• Work Group Members
• General Description of Guideline Format
• Target Population
• Priority Aims for Medical Groups When Using This Guideline
• Clinical Algorithm & Annotations
• Evidence Grading System
• Guideline Development History
• Other Guidelines Referenced Within This Guideline
• Instructions for Downloading PDF Version of This Guideline

Work Group Members

Work Group Leaders
John Farr, MD, HealthEast Comprehensive, OB-Gyn

John Hering, MD, HealthPartners

Deborah Thorp, MD, HealthSystem Minnesota

Family Practice
Vicki Jacobsen, MD, Mayo Clinic

Ob/Gyn
Dale Akkerman, MD, HealthSystem Minnesota

John Farr, MD, HealthEast Comprehensive, OB-Gyn

John Hering, MD, HealthPartners

John Jefferies, MD, Mayo Clinic

Charles Stegeman, MD, HealthPartners

Nurse Midwifery
Cherida McCall, CNM, HealthPartners

Beth Reinhart, CNM, HealthEast Comprehensive, OB-Gyn

Michelle Stegeman, CNM, HealthPartners

Susan Tighe, CNM, HealthEast Comprehensive, OB-Gyn

Nursing
Kathy Halvorson, RN, Honeywell, Inc.

Health Education
Dianne Eggen, RN, MPH, HealthPartners

Measurement Advisor
Rick Carlson, MS, HealthPartners

Facilitator
Teresa L. Rogstad, ICSI

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Target Population

All pregnant women with a previous Cesarean section.

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Priority Aims for Medical Groups When Using This Guideline

1. To decrease the number of repeat Cesarean sections which are not medically indicated.

Possible measures of accomplishing this aim:

a. Percentage of births delivering vaginally among patients who had a previous Cesarean section.

b. Percentage of births delivering vaginally among patients who had a previous Cesarean section among those attempting VBAC.

2. To increase the percentage of women who are eligible for VBAC who attempt VBAC.

Possible measures of accomplishing this aim:

a. Percentage of VBAC eligible women who attempted VBAC.

b. Percentage of women with VBAC eligible Cesarean sections who are counseled that VBAC is an option.

3. To increase the percentage of VBAC eligible women who receive education describing risks and benefits of VBAC.

Possible measures of accomplishing this aim:

a. Percentage of VBAC eligible women who receive education describing risks and benefits of VBAC.

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Clinical Algorithm & Annotations

• Algorithm Annotation List
  1.   First Office Visit
  2.   Contraindications to VBAC?
  3.   Routine Prenatal Care and Appropriately Timed C-section
  4.   Discuss Risks/Benefits with Patient and Document
  6.   Routine Prenatal Care Until Labor
  7.   Special Considerations of Labor Management
  9.   Complicated Labor Management
• Discussion and References: Download PDF Version of This Guideline

1. First Office Visit

A. Review and document operative reports.

B. Perform thorough history and physical.

C. Obtain necessary consultations from other specialists.

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2. Contraindications to VBAC?

A. Contraindications to VBAC:

1. Previous classic C-section.
   Evidence supporting this conclusion is of classes: C, D, R
2. Some uterine surgery, i.e., hysterotomy, deep myomectomy, cornual resection, and mettroplasty.
   Evidence supporting this conclusion is of class: R
3. Previous uterine rupture or dehiscence.
   Evidence supporting this conclusion is of class: D
4. Some maternal/fetal medical conditions, such as open neural tube defect and complete placenta previa.
5. Unknown uterine scar if there is a high likelihood of classical scar.
   Evidence supporting this conclusion is of class: D
6. Rare psychological or social conditions.
   Evidence supporting this conclusion is of class: R

B. Conditions that are not contraindications:

1. Two or more previous C-sections.
   Evidence supporting this conclusion is of class: X
2. Previous failure to progress in labor and/or CPD.
   Evidence supporting this conclusion is of classes: C, D
3. Post C-section infection.
   Evidence supporting this conclusion is of class: C
4. Vaginal delivery with a known overdistended uterus, i.e., twins, macrosomia, hydramnios.
   Evidence supporting this conclusion is of classes: C, D

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3. Routine Prenatal Care and Appropriately Timed C-section

See the ICSI Routine Prenatal Care guideline.

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4. Discuss Risks/Benefits with Patient and Document

Provide patient education, including a discussion of the risks and benefits associated with VBAC. Encourage VBAC in appropriate patients (See Annotation #2).

Document this discussion.

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6. Routine Prenatal Care Until Labor

See the ICSI Routine Prenatal Care guideline.

Attempt at external version is not a contraindication for VBAC.

Evidence supporting this conclusion is of class: D

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7. Special Considerations of Labor Management

A. C-section team availability within a short time (20-30 min).
     Evidence supporting this conclusion is of class: R

B. Intermittent auscultation or continuous electronic fetal heart rate monitoring should be done.

C. Depending on institution and status of patient, IV access, and type and screen of blood products may be done at a provider's discretion.

D. Augmentation or induction of labor is not contraindicated.
     Evidence supporting this conclusion is of classes: D, M

E. Uterine scars do not require manual exploration post-partum.
    Evidence supporting this conclusion is of class: D

F. Epidural anesthesia is not contraindicated.
    Evidence supporting this conclusion is of classes: C, D

G. Amnioinfusion is not contraindicated.
     Evidence supporting this conclusion is of class: D

H. Intrauterine pressure catheters are not necessary unless there are other obstetric indications.
     Evidence supporting this conclusion is of class: C

I. The use of prostaglandin gel in women with previous c-sections has not been thoroughly studied. Each situation should be weighed individually.

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9. Complicated Labor Management

Complicated labor results from:

A. Failure to progress. (See the ICSI Prevention, Diagnosis and Treatment of Failure to Progress in Obstetrical Labor guideline.)

Evidence supporting this conclusion is of classes: C, D

B. Fetal distress. (See the ICSI Intrapartum Fetal Heart Rate Management guideline.)

C. Maternal Complication.

D. Uterine Rupture.

The same considerations for intervention in labor apply to VBACs as for other attempted deliveries.

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Evidence Grading
I. CLASSES OF RESEARCH REPORTS

A. Primary Reports of New Data Collection:

Class A: Randomized, controlled trial

Class B: Prospective cohort study
Case-control study nested within a prospective cohort study

Class C: Non-randomized trial with concurrent or historical controls
Case-control study (except as above)
Retrospective cohort study
Study of sensitivity and specificity of a diagnostic test
Population-based descriptive study

Class D: Cross-sectional study
Case series
Case report

B. Reports that Synthesize or Reflect upon Collections of Primary Reports:

Class M: Meta-analysis
Decision analysis
Cost-benefit analysis
Cost-effectiveness study

Class R: Review article
Consensus statement
Consensus report

Class X: Medical Opinion

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Guideline Development History

• Document Drafted May - Aug 1993
• Critical Review Period Aug - Sep 1993
• Revision/Approval Oct - Dec 1993
• Pilot Implementation Period Dec 1993 - Apr 1994
• Revision/Approval May - Sep 1994
• General Implementation (First Cycle) Sep 1994 - Jun 1995
• Revision/Approval Jul - Sep 1995
• General Implementation (Second Cycle) Oct 1995 - Jun 1996
• Revision/Approval Jul - Nov 1996
• General Implementation (Third Cycle) Dec 1996 - Jul 1997
• Revision/Approval Aug - Oct 1997
• General Implementation (Fourth Cycle) Nov 1997 - Jul 1998
• Revision/Approval Aug - Nov 1998
• General Implementation (Fifth Cycle) Begins Dec 1998

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Other Guidelines Referenced Within This Guideline

• Routine Prenatal Care
• Prevention, Diagnosis nad Treatment of Failure to Progress in Labor
• Intrapartum Fetal Heart Rate Management

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Downloading the PDF Version of This Guideline

Click here to download the full version of this Guideline in PDF format. You will need ADOBE Acrobat reader to view the file. The reader may be found here.

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