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VAGINAL BIRTH AFTER

CAESAREAN SECTION
(VBAC)
BY
DR. E.O.OBI-THOMAS
• INTRODUCTION
• NOMENCLATURE
• INCIDENCE
• TYPES OF INCISION
• INDICATORS THAT GOVERN OUTCOME OF VBAC
– FAVOURABLE
– UNFAVOURABLE
• MANAGEMENT OPTIONS
– PRECONCEPTION PERIOD
– ANTENATAL PERIOD
– INTRAPARTUM
– PUERPERIUM
• CONTENTIOUS ISSUES
• ADVANTAGES
• SET BACKS
• CONCLUSION
Introduction

• VBAC phenomenon was observed in the


second half of last century by chance.
• Once a caesarean always a caesarean
founded on fear of uterine rupture with
classical scar.
• Dewhurst noted that in 1957 lower uterine
segment scar ruptured and not only in
classical scar.
• By 1980 ACO&G formally enclosed a
policy of trial of labour for reducing
Caesarea section.
• Various countries endorsed VBAC with
varying degree of urgency.
Nomenclature
• From lex caesarea in 700 BC
• From Latin word caedere (to cut) or
caesum (cut)
• Hysterctomy could be vaginal birth after
hysterctomy.(VBAH)
Incidence
• Success rate 52 – 80%, (lloabachie –
Lovell and Adair)
• West Africa – 60 (Klufio, Egwuatu
Onitfade)
Types of incisions
• Classical
• Lower uterine segment
• Transverse incision
• De Lee
• “J”-incision
Indicators that govern outcome
of VBAC
• CS was safe with advent of modern bld
Transfusion, safer anaesthesia and
powerful antibiotics.
• Rate of maternal Mortality is still high,
ranging from 4-26 times that of vaginal
route. (Hale, Creightonx and penn
• Risks ranging from anaesthetic through
surgical to immediate and long term
complications: Puerpeual endomestritis
(10 times greater)
– Bound injury, Bladder injury, Ureteric
injury, Infections, aspiration pneumonitis
(mendelson’s syndrome, DVT and Pul.
Embolism, More cost, longer Hospital stay,
Delay in mother baby bonding
• A Favourable factors
– Hx of previous vaginal birth before or after
CS
– If there was no non-recurrent factor for the
previous CS like malpresentation, PIH,
social reasons, multiple gestation breech,
CPD, etc
– Non-classical incision.
– Absence of morbidity in previous CS as evidenced by
normal hospital stay
– Bishop Score
– No hx of uterine perforation in attempt at TOP after
CS.
These scores are more applicable in
developed countries.
• B Unfavourable factors
– Fetal macrosomia
– IUGR
– Fetal asphyxia
– Short birth interval especially inter pregnancy interval
less than 6 months
– Age, parity, CPD do not impede VBAC
Management options
• A Preconception period –
– Counseling
– Hysterosalpingography
– Ultrasound
– Sonohysterography
– Erect lateral pelvimetry
– CT
– MRI
• B Antenatal period
– Basically as with most other pregnant women esp.
where appropriate preconception care has been given
to assess scar thickness and bony pelvic
measurement.
• Past obstetric history
• Ultrasound measuring 3.5mm or more at 36 wk
of gestation is adequate (Rozenberg et al)
• Clinical pelvimetry at 36 wks of gestation where
pelvic measurement is unknown prior to
conception.
• Radiological
• CT scan (20%)
• MRI
• Attempt to assess size of fetus is important as
macrosomia or IUGR determine outcome of
VBAC.
• Before 37 wks of gestation decision to undertake
or not to undertake VBAC should have been
taken.
C Intrapartum
• There must be facilities to carry out CS.
• Anaestghesiology and neonatology coverage
must be available.
• Group and Xmatch bld
• Wide bore canulla
• IVF slowly throughout labour and one hour after
labour.
• Active management of all stages of labour.
• Continous cardiotocographic monitoring.
• Intrauterine pressure monitoring if memb.
ruptured - controvasial
• Monitor labour on partogram. Important indices
to look out for are –
– Vaginal bleeding
– Urine colour
– Maternal pulse.
– Maternal BP
– Fetal heart rate
• Time for intervention is when there is evidence
of scar rupture, fetal distress, slow progress in
labour or CPD.
Evidence of scar disruption
• Continuous abd pain
• Cessation of uterine contraction.
• Vaginal bleeding.
• Maternal tachycardia
• FHR abnomaliies
• Haematuria.
D Puerperium
• Managed as other birth by vaginal route.
Contentious issues
• Oxytocin and prostaglandin for induction or
angumentation of labour.
• Use of epidural analgesia.
• Digital exploration of lower uterine segment.
• Breech and ECV
• VBAC after 2 or more CS
Set backs
• Failure to achieve vaginal delivery.
• Compelling recourse to a repeat CS
• Failure to convince certain women who had
undergone difficult labour in a previous
pregnancy to accept VBAC esp. with previous
dystocia, malpresentation, fetal distress, fetal
macrosomia, oxygen use and gestation age at
previous CS
• Poor hospital facilities
• Economic factors
• Illiteracy levels
• Churches.
Advantages
• Reduction of CS and its hazards
• Cheap
• Reduce hospital stay
• Enhance mother baby bonding.
Prevention
• By reducing 10 CX
CONCLUSION
VBAC should be practised within the ambit of the
available facilities in a given health care institution
so as not to compromise safety. Developing
countries need to take up the challenges posed to
them by the practice of VBAC especially in the
area of acquiring complex but sensitive modern
facilities for managing women at preconception
antenatal and intrapartum periods. Obstetricians
are better for it if the fear of uterine disruption is
put away and VBAC finds a firm place in their
obstetric practice.