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Evidence to Improve Care

Vaginal Birth After Caesarean (VBAC)

Care for People Who Have Had a Caesarean Birth and Are Planning Their Next Birth

Click below to see a list of brief quality statements and scroll down for more information.​​


Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence. ​

See below for the quality statements and click for more detail.​


Quality Statement 1: Access to Vaginal Birth After Caesarean
People who have had a Caesarean birth before can plan a vaginal birth for their next birth, as long as there is no medical reason not to have one.


Quality Statement 2: Discussion After Caesarean Birth
After a Caesarean birth, people have a discussion with their physician or midwife and receive written information about the reasons for their Caesarean birth and their options for future births.


Quality Statement 3: Shared Decision-Making
Pregnant people who have had a previous Caesarean birth participate in shared decision-making with their physician or midwife. The discussion and planned mode of birth is documented in the perinatal record.


Quality Statement 4: Previous Vaginal Birth
Pregnant people who have had both a previous Caesarean birth and a previous vaginal birth are informed that they have a high likelihood of successful vaginal birth if no contraindication is present.


Quality Statement 5: Operative Reports and Incision Type
Physicians and midwives obtain an operative report from any previous Caesarean births whenever possible. Pregnant people who have had a previous Caesarean birth with an unknown type of uterine incision have an individualized assessment by their physician or midwife to determine the likelihood of a low transverse incision.


Quality Statement 6: Timely Access to Caesarean Birth
Pregnant people planning a vaginal birth after Caesarean are aware of the resources available and not available at their planned place of birth, including physician, midwifery, nursing, anesthesiology, and neonatal care, and the ability to provide timely access to Caesarean birth.


Quality Statement 7: Unplanned Labour
Pregnant people planning an elective repeat Caesarean section should have a documented discussion with their physician or midwife about the feasibility of vaginal birth after Caesarean if they go into unplanned labour. This discussion should take place during antenatal care and again if the person arrives at the hospital in labour.


Quality Statement 8: Induction and Augmentation of Labour
Pregnant people who have had a previous Caesarean birth are offered induction and/or oxytocin augmentation of labour when medically indicated, and are informed by their physician or midwife about the potential benefits and harms associated with the method proposed. Discussion about this should begin in the antenatal period.


Quality Statement 9: Signs and Symptoms of Uterine Rupture
During active labour, pregnant people who have had a previous Caesarean birth are closely monitored for signs or symptoms of uterine rupture.


3

Shared Decision-Making

Pregnant people who have had a previous Caesarean birth participate in shared decision-making with their physician or midwife. The discussion and planned mode of birth is documented in the perinatal record.


Eligible pregnant people who have had a previous Caesarean birth should receive counselling on both planned vaginal birth after Caesarean (VBAC) and elective repeat Caesarean section. The choice of mode of birth requires shared decision-making and considers the person’s values and preferences, the outcomes of the previous Caesarean birth and previous operative report, the person’s risk profile, and clinical factors relevant to the current pregnancy. This process also includes the person’s partner or family, if desired.

Physicians and midwives should inform pregnant people who have had a previous Caesarean birth that VBAC is safe for most people, but not without risk. Antenatal counselling should include information about preparedness during labour (e.g., electronic fetal monitoring, IV access, and immediate access to Caesarean section) and unbiased information about the benefits and potential harms of VBAC versus elective repeat Caesarean section, including:

  • Expected post-pregnancy function, pain, and recovery time

  • Potential complications

  • Potential maternal and neonatal morbidity and mortality

  • Implications for future pregnancies

The risk of uterine rupture during labour after previous Caesarean is estimated to be 1 in 200. Uterine rupture requires an emergency Caesarean section, and it increases the risk of maternal bleeding and the need for a hysterectomy. Uterine rupture may result in maternal or perinatal death if a Caesarean section is not performed quickly enough. The use of a decision aid is recommended to facilitate best practices in shared decision-making, informed consent, and documentation. Decision aids present risk information in a balanced and comprehensive manner, to help the person clarify their preferences, which supports informed decision-making.

Physicians and midwives should document antenatal counselling on VBAC, the person’s decision about their planned mode of birth, and a plan for mode of birth if spontaneous labour occurs before the scheduled delivery date when elective repeat Caesarean section is chosen.

For Pregnant People

When you are choosing how you want to give birth, you and your physician or midwife should work together to make decisions. Conversations should include what is important to you about your birth experience, and the benefits and possible harms of both vaginal birth after Caesarean and a planned repeat Caesarean section.


For Clinicians

Provide antenatal counselling that supports shared decision-making for the planned mode of birth and offer VBAC when appropriate. Document the discussion and the planned mode of birth in the perinatal record.


For Health Services

Ensure that systems are in place so that physicians and midwives have the skills to support shared decision-making and document the discussion and planned mode of birth in the perinatal record.

Process Indicators

Percentage of pregnant people who have had a previous Caesarean birth and who have a documented discussion with their physician or midwife about their values and preferences, the benefits and potential harms of planned VBAC, and the benefits and potential harms of elective repeat Caesarean section

  • Denominator: number of pregnant people who have had a previous Caesarean birth

  • Numerator: number of people in the denominator who have a documented discussion with their physician or midwife about their values and preferences, the benefits and potential harms of planned VBAC, and the benefits and potential harms of elective repeat Caesarean section

  • Data source: local data collection


Percentage of pregnant people who have had a previous Caesarean birth and whose planned mode of birth is documented in their clinical chart

  • Denominator: number of pregnant people who have had a previous Caesarean birth

  • Numerator: number of people in the denominator whose planned mode of birth is documented in their clinical chart

  • Data source: Better Outcomes Registry and Network


Perinatal record

Standardized documentation of perinatal care. The Ontario Perinatal Record, 2016 version, acts as a care map for pregnancy, birth, and the very early newborn period.


Shared decision-making

A collaborative process that allows people and their health care professionals to make decisions together. The health care professional:

  • Invites the person to participate

  • Presents options

  • Provides information about the benefits and potential harms of each option, as well as care during labour and discussion of potential interventions

  • Helps people evaluate the options based on their values and preferences

  • Facilitates deliberation and decision-making

  • Helps implement decisions

  • Provides decision-making aids or other tools


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