Guideline:
Birth after previous caesarean
Bibliographic Source(s)
- Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean birth. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2007 Feb. 17 p. (Green-top guideline; no. 45). [116 references]
Guideline Status
This is the current release of the guideline.
Guideline Category
Counseling
Evaluation
Management
Prevention
Risk Assessment
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
To provide evidence-based information to inform the care of women undergoing either planned vaginal birth after previous caesarean section or elective repeat caesarean section
Target Population
Pregnant women who have had a previous cesarean section
Interventions and Practices Considered
- Antenatal counseling regarding benefits and risks of vaginal birth after cesarean section (VBAC)
- Counseling for planned VBAC in special circumstances
- Preterm birth
- Twin gestation fetal macrosomia short interdelivery interval
- Intrapartum support and intervention during planned VBAC
- Epidural anesthesia
- Continuous fetal electronic monitoring
- Diagnosis of uterine scar rupture
- Counseling regarding risks of induction and augmentation of labor (oxytocin)
Major Outcomes Considered
- Rate of vaginal birth after previous cesarean section
- Rate of elective repeat cesarean section
- Maternal morbidity and mortality
- Term perinatal morbidity and mortality
- Term delivery-related perinatal mortality
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Electronic searches were performed in Medline (Ovid version 1996–October 2006) and EMBASE (Ovid version 1996–October 2006) using relevant medical subject headings and text words. Evidence-based reviews and guidance from the American College of Obstetricians and Gynecologists the Society of Obstetricians and Gynaecologists of Canada the US Agency for Healthcare Research and Quality the New Zealand Guidelines Group and the Cochrane Database of Systematic Reviews (2006) were identified and used in the development of this guideline.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence
Ia: Evidence obtained from meta-analyses of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies such as comparative studies correlation studies and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
The recommendations were graded according to the level of evidence upon which they were based. The grading scheme used was based on a scheme formulated by the Clinical Outcomes Group of the National Health Service Executive.
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. (Evidence levels Ia Ib)
Grade B - Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. (Evidence levels IIa IIb III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. (Evidence level IV)
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
Following discussion in the Guidelines and Audit Committee each green-top guideline is formally peer reviewed. At the same time the draft guideline is published on the Royal College of Obstetricians and Gynaecologists Web site for further peer review discussion before final publication.
The names of author(s) and nominated peer reviewers are included in the original guideline document.
Major Recommendations
In addition to these evidence-based recommendations the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
Antenatal Counselling
How Should Women be Counselled in the Antenatal Period?
B - Women considering their options for birth after a single previous caesarean should be informed that overall the chances of successful planned vaginal birth after previous caesarean section (VBAC) are 72 to 76%.
All women who have experienced a prior caesarean birth should be counselled about the maternal and perinatal risks and benefits of planned VBAC and elective repeat caesarean section (ERCS) when deciding the mode of birth. The key issues to include in the discussion are listed below under specific risks and benefits (see "What are the Specific Risks and Benefits of VBAC" below). (Evidence level IV)
The risks and benefits should be discussed in the context of the woman's individual circumstances including her personal motivation and preferences to achieve vaginal birth or ERCS her attitudes towards the risk of rare but serious adverse outcomes her plans for future pregnancies and her chance of a successful VBAC (principally whether she has previously had a vaginal birth; see discussion under section 6.1 in the original guideline document). In addition where possible there should be review of the operative notes of the previous caesarean to identify the indication type of uterine incision and any perioperative complications. (Evidence level IV)
What are the Contraindications to VBAC?
C - Women with a previous uterine incision other than an uncomplicated low transverse caesarean section incision who wish to consider vaginal birth should be assessed by a consultant with full access to the details of the previous surgery.
B - Women with a prior history of two uncomplicated low transverse caesarean sections in an otherwise uncomplicated pregnancy at term with no contraindication for vaginal birth who have been fully informed by a consultant obstetrician may be considered suitable for planned VBAC.
There is limited evidence on whether maternal or neonatal outcomes are significantly influenced by the number of prior caesarean births or type of prior uterine scar. Nonetheless due to higher absolute risks of uterine rupture or unknown risks planned VBAC is contraindicated in women with:
- Previous uterine rupture—risk of recurrent rupture is unknown
- Previous high vertical classical caesarean section (200–900/10000 risk of uterine rupture) where the uterine incision has involved the whole length of the uterine corpus
- Three or more previous caesarean deliveries (reliable estimate of risks of rupture unknown). (Evidence level IIb III and IV)
However it is recognised that in certain extreme circumstances (such as miscarriage intrauterine fetal death) for some women in the above groups the vaginal route (although risky) may not necessarily be contraindicated. A number of other variants are associated with an increased risk of uterine rupture. These include: women with a prior inverted T or J incision (190/10000 rupture risk) and women with prior low vertical incision (200/10000 rupture risk). (Evidence level IIa)
What are the Specific Risks and Benefits of VBAC?
B - Women considering the options for birth after a previous caesarean should be informed that planned VBAC carries a risk of uterine rupture of 22–74/10000. There is virtually no risk of uterine rupture in women undergoing ERCS.
B - Women considering the options for birth after a previous caesarean should be informed that planned VBAC compared with ERCS carries around 1% additional risk of either blood transfusion or endometritis.
B - Women considering planned VBAC should be informed that this decision carries a 2–3/10000 additional risk of birth-related perinatal death when compared with ERCS. The absolute risk of such birth-related perinatal loss is comparable to the risk for women having their first birth.
B - Women considering the options for birth after a previous caesarean should be informed that planned VBAC carries an 8/10000 risk of the infant developing hypoxic ischaemic encephalopathy (HIE). The effect on the long-term outcome of the infant upon experiencing HIE is unknown.
B - Women considering the options for birth after a previous caesarean should be informed that attempting VBAC probably reduces the risk that their baby will have respiratory problems after birth: rates are 2–3% with planned VBAC and 3–4% with ERCS.
B - Women considering the options for birth after a previous caesarean should be informed that the risk of anaesthetic complications is extremely low irrespective of whether they opt for planned VBAC or ERCS.
B - Women considering the options for birth after a previous caesarean should be informed that ERCS may increase the risk of serious complications in future pregnancies.
Planned VBAC In Special Circumstances
How Should Women be Counselled in the Context of Obstetric Complications?
Preterm Birth
B - Women who are preterm and considering the options for birth after a previous caesarean should be informed that planned preterm VBAC has similar success rates to planned term VBAC but with a lower risk of uterine rupture.
Twin Gestation Fetal Macrosomia Short Interdelivery Interval
C - A cautious approach is advised when considering planned VBAC in women with twin gestation fetal macrosomia and short interdelivery interval as there is uncertainty in the safety and efficacy of planned VBAC in such situations.
Intrapartum Support and Intervention During Planned VBAC
Where and How Should VBAC be Conducted?
B - Women should be advised that planned VBAC should be conducted in a suitably staffed and equipped delivery suite with continuous intrapartum care and monitoring and available resources for immediate caesarean section and advanced neonatal resuscitation.
Obstetric midwifery anaesthetic operating theatre neonatal and haematological support should be continuously available throughout planned VBAC and ERCS. (Evidence level IV)
C - Epidural anaesthesia is not contraindicated in planned VBAC.
B - Women should be advised to have continuous electronic fetal monitoring following the onset of uterine contractions for the duration of planned VBAC.
Early diagnosis of uterine scar rupture followed by expeditious laparotomy and resuscitation is essential to reduce associated morbidity and mortality in mother and infant. There is no single pathognomic clinical feature that is indicative of uterine rupture but the presence of any of the following peripartum should raise the concern of the possibility of this event:
- Abnormal cardiotocograph (CTG)
- Severe abdominal pain especially if persisting between contractions
- Chest pain or shoulder tip pain sudden onset of shortness of breath
- Acute onset scar tenderness
- Abnormal vaginal bleeding or haematuria
- Cessation of previously efficient uterine activity
- Maternal tachycardia hypotension or shock
- Loss of station of the presenting part
The diagnosis is ultimately confirmed at emergency caesarean section or postpartum laparotomy. (Evidence levels III IV)
Induction and Augmentation
How Should Women with a Previous Caesarean Birth Be Advised in Relation to Induction of Labour or Augmentation?
B - Women should be informed of the two- to three-fold increased risk of uterine rupture and around 1.5-fold increased risk of caesarean section in induced and/or augmented labours compared with spontaneous labours.
The additional risks in augmented VBAC mean that:
- Although augmentation is not contraindicated it should only be preceded by careful obstetric assessment maternal counselling and by a consultant-led decision.
- Oxytocin augmentation should be titrated such that it should not exceed the maximum rate of contractions of four in 10 minutes; the ideal contraction frequency would be three to four in 10 minutes.
- Careful serial cervical assessments preferably by the same person are necessary to show adequate cervicometric progress thereby allowing augmentation to continue.
The intervals for serial vaginal examination and the selected parameters of progress that would necessitate discontinuing VBAC labour should be consultant-led decisions.
When informing a woman about induction (prostaglandin or non-prostaglandin methods) and/or augmentation clear information should be provided on all potential risks and benefits of such a decision and how this may impact on her long-term health. For example women who are contemplating future pregnancies may accept the short-term additional risks associated with induction and/or augmentation in view of the reduced risk of serious complications in future pregnancies if they have a successful VBAC. (Evidence level IV)
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. (Evidence levels Ia Ib)
Grade B - Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. (Evidence levels IIa IIb III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. (Evidence level IV)
Levels of Evidence
Ia: Evidence obtained from meta-analyses of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies such as comparative studies correlation studies and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations" field).
Potential Benefits
Appropriate counseling and decision making regarding mode of delivery after previous cesarean birth
Potential Harms
- Rates of hysterectomy and transfusion increase in women undergoing vaginal birth after previous caesarean section (VBAC) following two or more previous caesarean births compared to a single previous caesarean birth.
- Planned VBAC carries a risk of uterine rupture of 22–74/10000. There is virtually no risk of uterine rupture in women undergoing elective repeat caesarean section (ERCS).
- Planned VBAC compared with ERCS carries around 1% additional risk of either blood transfusion or endometritis.
- Planned VBAC carries a 2–3/10000 additional risk of birth-related perinatal death when compared with ERCS.
- Planned VBAC carries an 8/10000 risk of the infant developing hypoxic ischaemic encephalopathy.
- There is an increased risk of neonatal respiratory morbidity (defined earlier) among term infants delivered by elective caesarean (3.5–3.7%) compared with vaginal birth (0.5–1.4%).
- The following risks significantly increase with increasing number of repeated caesarean deliveries: placenta accreta; injury to bladder bowel or ureter; ileus; the need for postoperative ventilation; intensive care unit admission; hysterectomy; blood transfusion requiring four or more units and the duration of operative time and hospital stay.
- Infants of mothers who received epidural analgesia were more likely to be subjected to diagnostic tests and therapeutic interventions (including sepsis evaluation and antibiotic treatment) compared with infants from a matched no-epidural analgesia group
- There is a higher risk of uterine rupture with induction of labour with prostaglandins.
Contraindications
- Due to higher absolute risks of uterine rupture or unknown risks planned vaginal birth after previous caesarean section is contraindicated in women with:
- Previous uterine rupture—risk of recurrent rupture is unknown
- Previous high vertical classical caesarean section (200–900/10000 risk of uterine rupture) where the uterine incision has involved the whole length of the uterine corpus.
- Three or more previous caesarean deliveries (reliable estimate of risks of rupture unknown)
However it is recognized that in certain extreme circumstances (such as miscarriage intrauterine fetal death) for some women in the above groups the vaginal route (although risky) may not necessarily be contraindicated.
Qualifying Statements
- These guidelines are "systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions." Each guideline is systematically developed using a standardised methodology. Exact details of this process can be found in Clinical Governance Advice No. 1: Guidance for the Development of RCOG Green-top Guidelines (See the "Availability of Companion Documents" field in this summary.)
- These recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual patient needs resources and limitations unique to the institution and variations in local populations. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated.
Limitations of Data Used in This Guideline
There are no randomised controlled trials comparing planned vaginal birth after cesarean section (VBAC) with planned elective repeat caesarean section (ERCS) and this may be an unrealistic aspiration. Evidence for these interventions is obtained mainly from retrospective nonrandomized studies. Furthermore many of the main outcomes of interest are relatively uncommon. Adequately powered studies require large numbers and these frequently rely on routinely collected data. Consequently many studies have limitations in terms of definition of exposures and outcomes ascertainment bias and selection bias. Furthermore the consequent interstudy heterogeneity precludes reliable meta- analyses. A recently published study by the National Institute of Child Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network has overcome many of these shortcomings by having a large sample size a prospective cohort design and by using standardised definitions for assessing outcomes. However this comparison is undermined by the fact that the group delivered by ERCS in that study included women in whom planned VBAC was absolutely or relatively contraindicated such as women with placenta praevia high numbers of previous caesarean births or maternal medical disorders. Therefore the presence of these conditions may have led to an overestimate of the risk of adverse outcomes associated with ERCS.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Audit Criteria/Indicators
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety
Bibliographic Source(s)
- Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean birth. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2007 Feb. 17 p. (Green-top guideline; no. 45). [116 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Royal College of Obstetricians and Gynaecologists
Guideline Committee
Guidelines and Audit Committee
Composition of Group that Authored the Guideline
Authors: Mr R Varma MRCOG Birmingham; Professor JK Gupta FRCOG Birmingham; and Professor GCS Smith MRCOG Cambridge
Financial Disclosures/Conflicts of Interest
Guideline authors are required to complete a "declaration of interests" form.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site.
Print copies: Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Bookshop 27 Sussex Place Regent's Park London NW1 4RG; Telephone: +44 020 7772 6276; Fax +44 020 7772 5991; e-mail: bookshop@rcog.org.uk. A listing and order form are available from the RCOG Web site.
Availability of Companion Documents
The following are available:
- Development of RCOG green-top guidelines: policies and processes. Clinical Governance Advice No 1a. 2006 Nov. Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site.
- Development of RCOG green-top guidelines: producing a scope. Clinical Governance Advice No 1b. 2006 Nov. Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site.
- Development of RCOG green-top guidelines: producing a clinical practice guideline. Clinical Governance Advice No 1c. 2006 Nov. Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site.
- Searching for evidence. Clinical Governance Advice No 3. 2001 Oct. Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site.
Additionally auditable standards can be found in section 10 of the original guideline document.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI Institute on November 28 2007.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.