Antenatal counseling in management of VBAC ( vaginal birth after cesarean section)

     Management of VBAC should be started from antenatal phase, that is before delivery. During this phase, a woman with previous history of cesarean section, who is a suitable candidate for VBAC, is counseled on the option of planned VBAC and the other alternative option of elective repeat cesarean section for mode of delivery. A final decision for mode of delivery should be agreed between the woman and her obstetrician before the expected / planned delivery date, ideally by 36 weeks of gestation. Thus, ideally the woman should be counseled earlier so that she has enough time to understand all the information given to her, to consider both options and finally to make her decision.

     Women considering their option for birth should be informed that, overall, chances of successful planned VBAC are 72 - 76%. They should be informed about the factors associated with successful VBAC as well as factors associated with unsuccessful VBAC - which unsuccessful VBAC means that the woman has to proceed with emergency cesarean section for delivery. They also should be counseled on the contraindication, specific risks and benefits of VBAC. 

    The consultant will do details and thorough assessment to determine wether the woman is contraindicated or not for VBAC. Women with contraindication of VBAC is not suitable for VBAC, thus they are recommended to give birth by ERCS (elective repeated cesarean section).

     Factor associated with successful VBAC mainly is previous vaginal birth, particularly previous successful VBAC. Meanwhile, factors that associated with unsuccessful VBAC include: 1)induced labor. 2)no previous vaginal birth. 3)BMI greater than 30. 4)previous cesarean section for dystocia. 5) VBAC at or after 41 weeks gestation. 6)birth weight greater than 4kg. 7)previous preterm cesarean birth. 8)cervical dilatation at admission less than 4 cm. 9)less than 2 years of previous cesarean birth. 10) advanced maternal age, and so on. 

     Women considering the option for VBAC should as well be told that 1)planned VBAC carries a risk of uterine rupture of 22 - 74/10,000. There is virtually no risk of uterine rupture in woman undergoing ERCS. 2)planned VBAC compared to ERCS carries around 1% additional risk of either blood transfusion and endometritis. 3)planned VBAC carries around 2 - 3/10,000 additional risk of birth related perinatal death compared to ERCS. The absolute risk of such birth related perinatal loss is comparable to the risk for women having their 1st birth. 4)planned VBAC carries an 8/10,000 risk of infant developing HIE (hypoxic ischemic encephalopathy). 5)planned VBAC reduce the risk that their baby will have respiratory problems after birth. Rates are 2 - 3% with planned VBAC and 3 - 4% with ERCS. 6)risk of anesthetic complication is extremely low, irrespective of wether they opt for planned VBAC or ERCS. 7)ERCS may increase risk of serious complication in future pregnancies.

Vaginal birth after caesarean section

                Caesarean section or C-section is a surgical procedure used to deliver a baby through an incision made in the mother’s abdomen (laparotomy) and a second incision made in the mother’s uterus (hysterotomy). Meanwhile, vaginal birth after caesarean section or VBAC occurs when a woman having a vaginal delivery when she has had at least one baby by caesarean section previously.

               

                A woman underwent a caesarean section for few reasons. It can be due to maternal indication, or baby indication, or both. Maternal indications that lead to caesarean section include previous history of caesarean section, obstruction of birth canal such as tumor in the birth canal causing delivery to be obstructed, and pelvic abnormalities such as small pelvis. Fetal indications include breech, congenital malformation, compromised fetal condition, and so on.

                Every procedure will have its own complication. Same goes with C-section. Complication that may arise from C-section include infection which can arise from the wound itself or from other source such as urinary tract infection, thromboembolic disease such as deep vein thrombosis, anesthetic complication, injury to adjacent organ of the uterus such as bladder and bowel, uterine atony which the uterus unable to contract well after delivery causing bleeding from the uterus and so on.

                Maternal complications increase with Caesarean delivery relatively compared to a vaginal delivery. Thus VBAC may avoid some of the suitable candidate from encounter complication of C-section. However, not all candidate is suitable for VBAC. This is because there is risk for ‘uterine scar rupture’ for those who opted for VBAC. Therefore, candidates with high risk for uterine scar rupture are not suitable for this option, and they have to proceed with C-section.

                There are few criteria to be considered before making VBAC an option for delivery: 1) One previous low transverse C-section. 2) Clinically adequate pelvis. 3) No other uterine scar / previous uterine scar rupture. 4) A physician immediately available throughout active labor who is capable of monitoring labor and performing an emergency delivery (when indicated). 5) Availability of anesthesia and personnel for emergency C-section.