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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.


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.


Evidence suggests that compared with spontaneous labour, induction or augmentation of labour after a previous Caesarean delivery increases the risk of uterine rupture by 2 to 3 times, and increases the risk of Caesarean birth by 1.5 times. However, because the absolute risk of uterine rupture is low, induction and augmentation of labour can be offered when the indication is appropriate and after counselling on potential benefits and harms. Physicians and midwives should talk with their patient or client about the decision to induce or augment labour, the proposed method to be used, time intervals for serial vaginal examination, and criteria for labour progress that would lead to discontinuing labour and proceeding to a Caesarean birth.

If oxytocin augmentation is used, clinicians should pay very close attention to labour progress and uterine activity. The use of oxytocin requires one-to-one nursing or midwifery care and continuous electronic fetal monitoring during active labour.

In people who have had a previous Caesarean birth, pregnancy that continues beyond 40 weeks is not a contraindication for labour. Induction of labour should be considered only after 41 weeks, unless there are other medical indications for it. Mechanical methods of induction such as amniotomy or Foley catheter cervical ripening are preferred, because they are associated with a smaller increased risk of uterine rupture. Misoprostol or prostaglandins should not be used during labour after Caesarean birth because of their association with a high risk of uterine rupture.

For Pregnant People

You may be offered drugs or other methods to speed up your labour if you need it. Be sure to talk with your physician or midwife about the benefits and potential harms of what they recommend.


For Clinicians

Offer induction and/or oxytocin augmentation of labour when medically indicated, and discuss the benefits and potential harms associated with the method proposed, including increased risk of uterine rupture. Do not use misoprostol to induce labour after Caesarean.


For Health Services

Ensure that physicians and midwives have the resources, knowledge, and skills to offer and monitor induction and/or oxytocin augmentation when medically indicated, and to discuss the benefits and potential harms associated with the method proposed.

Process Indicators

Percentage of pregnant people who attempt a vaginal birth after Caesarean and present with documented clinical indications for labour induction who receive labour induction

  • Denominator: number of pregnant people who attempt a vaginal birth after Caesarean and present with documented clinical indications for labour induction

  • Numerator: number of people in the denominator who receive labour induction

  • Data source: local data collection


Percentage of pregnant people who attempt a vaginal birth after Caesarean and present with documented clinical indications for labour augmentation who receive labour augmentation

  • Denominator: Number of pregnant people who attempt a vaginal birth after Caesarean and present with documented clinical indications for labour augmentation

  • Numerator: Number of people in the denominator who receive labour augmentation

  • Data source: Local data collection

Induction of labour

Starting contractions in a pregnant person who is not in labour to help achieve a vaginal birth within 24 to 48 hours.


Augmentation of labour

Stimulating the uterus to increase the frequency, duration, and intensity of contractions after spontaneous labour has started.

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