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VBAC clinically safe choice for most women

‘Green-top’ guideline says vaginal birth succeeds in 75% of cases – same as for first births

Louise Prime

Tuesday, 06 October 2015

Doctors can assure women that aiming for vaginal birth after caesarean (VBAC) is a clinically safe choice for most of them, and that they have just the same chance of achieving a successful vaginal birth as a first-time mother, according to the latest guidance. The new ‘Green-top’ guideline from the Royal College of Obstetricians and Gynaecologists says women should understand that both VBAC and repeat caesarean section are safe, and it recommends using a checklist to help decision making in individual cases.

In the second edition of Birth after previous caesarean birth, the RCOG cites evidence confirming that VBAC has a success rate of about 75%, which is the same as for first-time mothers. The success rate rises to 85-90% if the woman has previously had a successful vaginal birth; and even after two or more caesareans, the VBAC success rate is still as high as 71%.

The RCOG provides evidence-based information to help doctors advise women about the available choices for their baby’s birth, and to help them manage women’s care through subsequent pregnancies and births. It gives detailed guidance on how to assess women’s individual suitability for VBAC or repeat caesarean; for example, VBAC may not be recommended depending on factors including the baby’s presentation, type of previous caesarean incision, previous surgery, placental position and previous uterine rupture.

It also stresses the importance of doctors using a clinical checklist or clinical care pathway to guide best practice in antenatal counselling, shared decision making and documentation. It recommends that if there are no clinical contraindications to VBAC identified at the 20-week scan, the maternity team should begin talking to the mother and her partner about their options, and that by 36 weeks’ gestation they should have decided on their preferred option.

Lead guideline author, professor of obstetrics and gynaecology Janesh Gupta said: “Women can be assured that in most cases it is possible and safe to have a vaginal birth after a previous caesarean section. This guideline can be used to aid doctors in their assessment of individual women and, unless there are clinical reasons why a vaginal birth should not be attempted, help inform the woman and her partner of her choices and the risks involved with either vaginal birth or a repeat caesarean section.”

VBAC has a lower complication rate than a repeat caesarean section, and the extremely low risk of maternal mortality is the same as for primigravida. There is a one in 200 risk of uterine rupture, and a one in 1,000 risk of stillbirth after 39 weeks. Women who end up with a repeat caesarean after attempting VBAC have a higher risk of complications including haemorrhage or infection – 14.1%, compared with 2.4% for a successful VBAC and 3.6% for a planned repeat caesarean.

The College’s vice president of clinical quality Professor Alan Cameron said: “This updated guideline includes a new recommendation on the use of a checklist or clinical care pathway to make sure best practice is maintained, that women are counselled regarding their options and the risks with either a repeat caesarean or vaginal birth are fully explained to them.”

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