Did You Know: The National Obstetric Guidelines for Ireland include VBAC(2)?

What is a VBAC?

A VBAC is when a woman gives birth vaginally after a previous Caesarean Section. Sometimes, you will see a number following VBAC – this indicates that a woman has had more than one previous Caesarean Section. For example VBAC2 means a vaginal birth following two previous Caesarean Section.

With supportive and appropriate care, at least 70% of women who choose VBAC, will give birth without complications vaginally. Your maternity unit and individual health care providers should reflect this in their VBAC rates.

Why Choose VBAC?

There are many reasons why a woman may decide to choose a VBAC.
Some of these include:

* difficult or long recovery from surgery
* extended hospital stay
* complications with scar
* worry about recovery from surgery with small children
* disappointment following Caesarean Section
* desire to have control
* not wanting to be separated from your baby immediately following birth
* health concerns for your or your baby

Is vaginal birth following a Caesarean safe?

Uterine rupture is the main concern given to women choosing vaginal birth following a previous Caesarean Section. A uterine rupture is a tear in the wall of the uterus. Uterine rupture is usually associated with women with a previous Caesarean Section, however, this is not always the case. Sometimes, uterine rupture can occur with women with no previous Caesarean history. Vaginal birth, particularly when interventions are used to manage your labour or birth, can also increase your likelihood of other complications such as vaginal pain from stitches or episiotomy, assisted delivery, incontinence.

You are more likely to have a uterine rupture if your previous Caesarean was done with a vertical incision, rather than a low transverse incision.

The rate of uterine rupture in Ireland is low. The rate is 2 per 1000 women overall, or 1 per 1000 for women in spontaneous labour who did not receive oxytocin augmentation (Turner et al, 2006).

VBAC2 – Evidence for VBAC2 has shown that women choosing VBAC vs VBAC2 have similar rates of uncomplicated vaginal birth. The rate of major complications is slightly higher if you have had more than one previous Caesarean Section. However, while the risk of major complications is higher for women with 2 previous Caesarean Sections, when compared to the risks for elective Caesarean Section, the absolute risks of major complications are quite low. (AJOG)

VBAC3+ – There is very little evidence on vaginal birth following 3 or more Caesarean Sections. For women considering VBAC3 or more, your medical professionals need to provide you with information to make an informed decision on VBAC vs repeat Caesarean. This evidence must prove that VBAC3+ is unsafe – more unsafe than a repeat Caesarean.

Repeat Caesareans – Repeat Caesareans have many benefits but are not risk free. In fact, evidence shows us that risks to mothers and babies increase with each Caesarean Section. These risks can affect your current or subsequent pregnancies.

They include:

* increased risk of ectopic pregnancy in future pregnancies
* increased risk of placenta previa (when the placenta covers the cervix)
* increased risk of placental abruption (when the placenta comes away from the uterus before the baby is born)
* increased risk of placenta accrete (the placenta grows into or through the wall of the uterus)
* increases likelihood of problems for women – haemorrhage, blood clots, infection, scar pain
* increases time of hospital stay and the instances of re-admission
* longer recovery period
* increases the likelihood of problems for babies – admission to NICU, breathing problems, cuts from incision

What are VBAC guidelines in Ireland?
The Irish Guidelines “Delivery after previous caesarean section” (issued Oct 2011) are available on the HSE website.

You can read them in full here – #5: http://www.hse.ie/eng/about/Who/clinical/natclinprog/obsandgynaeprogramme/obsgyneguide.html

AIMS Ireland is in regular contact with women who choose VBAC2+ in Ireland who are not supported by care providers, even before individual assessment is considered. These guidelines are national guidelines for obstetric practice in Ireland. These guidelines are meant to provide guidance to the local policy of units in Ireland. VBAC2 is included into these guidelines as a care option in Ireland; though in a very restricted capacity.

Recommendations in The National Guideline provides a starting point for women choosing VBAC(2+) to open communication with care providers to aide informed decision making. Recommendations are not compulsory. Your care provider can advice you on any of the practices listed below, but its your decision on the day.

Main Points of recommendations include:


* incision site is low transverse and not vertical
* electronic fetal monitoring during labour
* where loss of contact with abdominal belt during monitoring, foetal scalp monitoring is recommended
* if electronic foetal monitoring shows abnormal results, foetal blood sampling is recommended
* oxytocin may be used if your labour is not progressing as required
* induction of labour is possible following 1 previous caesarean, however should only be based on medical need to mother or baby

VBAC2+ to be supported where:

* head is engaged
* cervix is favourable
* history of prior vaginal birth
* spontaneous labour

Continuous Monitoring in VBAC in Ireland

Continuous electronic foetal monitoring features heavily in the VBAC guidelines for Ireland.

Continuous foetal monitoring measures your baby’s heartbeat in frequency and strength and measures your contractions. Continuous monitoring can be either A) external – by a belt (CTG) which goes around your tummy or B) internal – a monitor which is attached to your baby through the top layer of your baby’s scalp.

The reason for continuous monitoring is that it will show if your baby’s oxygen levels are low or your baby is not tolerating labour well and to prevent cerebral palsy, brain damage, newborn seizures, or death or may prevent a uterine rupture.

However, the evidence shows us:

* CTG has been shown to be less accurate than internal foetal scalp monitoring.
* CTG has been shown to increase your chances of interventions, including Caesarean Section and assisted delivery
* there is no difference between intermittent monitoring and continuous monitoring for “perinatal mortality, cerebral palsy, Apgar scores, cord blood gasses, admission to the neonatal intensive care unit, or low-oxygen brain damage” Cochrane Review 2006
* there was less instance of newborn seizures when continuous monitoring was used
* intermittent monitoring has more benefits with no additional risks in low and high risk women

What women tell us:

* Electronic monitoring makes it difficult to move in labour.
* CTG very uncomfortable
* CTG makes contractions more difficult
* CTG makes women feel tied to the bed

June 2012, the HSE launched a guideline “Intrapartum Fetal Heart Rate Monitoring (issued June 2012)” – recommending no admissions trace and intermittent monitoring in labour for low risk mothers.

Read more on the evidence for intermittent vs continuous monitoring for low and high risk women here:
Evidence Based Birth http://evidencebasedbirth.com/evidence-based-fetal-monitoring/

For more information or to access AIMS Ireland support services please contact us at support@aimsireland.com

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