guidelines for vaginal birth after previous caesarean birth

8/14/2019 Guidelines for Vaginal Birth After Previous Caesarean Birth

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GUIDELINES FORGUIDELINES FOR

VAGINAL BIRTH AFTERVAGINAL BIRTH AFTERPREVIOUSPREVIOUS

CAESAREAN BIRTHCAESAREAN BIRTHDr .Ashraf Fouda

Egypt - Damietta GeneralHospital

E. mail :

[email protected]


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S.O.G.C.(Society ofObstetricians &Gynecologists ofCanada)

CLINICAL PRACTICE GUIDELINESThis document with articles publishedfromJanuary 1995 to February 2004,

obtained by searching the MEDLINEdatabase using the key words

vaginal birth after C.S.

SOURCE:

July 2004


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BACKGROUND

The most frequentindications for C.S are

previous C.S., dystocia,malpresentation, and non-

reassuring fetal status.The rate of birth by C.S.

and the rate of VBAC tend


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Schell first reportedVBAC in 1923,

describing the successfulvaginal delivery of

infants in mothers withprevious Caesarean

deliveries.

BACKGROUND


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A trial of labour afterC.S. should be

considered in womenwho present for

prenatal care with ahistory of previous

BACKGROUND


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In certain situations, TOLafter C.S. will be

contraindicated and arepeat C.S. will advised,

But in most cases,successful vaginal birth can

be achieved safely for both

BACKGROUND


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Women and their

health-care providerswill need to discuss

the risks and benefitsof VBAC when

planning the birth.

BACKGROUND


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The data obtained is limited by 3

important factors:

First, there are no randomized trials ofTOL versus elective repeat C.S. (ERCS);

Second, adverse maternal or perinataloutcomes are rare and large studypopulations are necessary to observe a

significant difference in maternal andperinatal outcomes; and,

Finally, the womans choice to attempt a

TOL after C.S. is heavily influenced by

BACKGROUND


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TRIAL OF LABOUR VERSUS ELECTIVE

REPEAT CAESAREAN SECTION

The success rate of trial oflabour after Caesarean rangesbetween 50% and85%.

In a study examining 1776women undergoing TOL after

Caesarean, the overall


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Predictors of successful VBACinclude nonrecurring

indication for Caesareanbirth, such as: Malpresentation , Gestational hypertension and

a

Previous vaginal delivery




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When the previous C.S. was for:

2. Dystocia,

3. Failure to progress, or

4. Cephalopelvic disproportion,

Some studies found the rates ofsuccessful VBAC comparable,

while others reported or

lower-than-expected rates.




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In 1996, McMahon et al. published areport ofmaternal morbidity in TOLcompared to ERCS from 1986 to 1992.

In an examination of3249 womenundergoingTOL and 2889 womenwho delivered by ERCS, the risk of

major complications (hysterectomy,uterine rupture, and operative injury)was almost doubled in the TOL group




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Complications like puerperalfever, transfusion and abdominalwound infection were

comparable.When comparing those who had

a successful TOL to those whorequired a repeat Caesareansection after failed TOL, the risks

were greater of operative injury




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In 1999, Rageth et al. reviewed 17613TOL and 11 433 ERCS deliveries.

The rates ofhysterectomy ,febrile

morbidity and thromboemboliccomplications were less in the TOLgroup than in the ERCS group.

There is less blood loss with asuccessful VBAC and a shorterhospital stay with more rapid

recovery and return to full activity.




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Rosen et al. also reported that therisk of febrile morbidity is lower in

women who attempt a TOL afterCaesarean and is lowest in thosewho succeed ,compared to ERCS,

But is increased in those whoattempt a TOL and ultimatelydeliver by Caesarean section.

TRIAL OF LABOUR VERSUS

ELECTIVE REPEAT CAESAREAN

SECTION


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An examination of 16 938women who had undergone aCaesarean delivery found

that previous C.S. isassociated with an increasedrisk of:

Ectopic pregnancy, Placenta previa , and

Abruptio placenta




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A repeat Caesarean

section has beenassociated with anincreased risk of :

Placenta previa and Placenta accreta

in subse uent



SECTION


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A meta-analysis

published in 2000demonstrated that the

overall risk ofperinataldeath is increased in

those attempting a TOL .



SECTION


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The risks of perinatalmortality and severe

morbidity are directly relatedto uterine rupture .

If uterine rupture occurs,the risk of perinatal mortality

and severe morbidity are




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The risk of suspectedneonatal sepsis is greater

in those attempting a TOLbut appears to be confined

to the group of TOL whofail and require a repeat

Caesarean section .



SECTION


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If an ERCS is chosen,

the risk ofrespiratoryproblems in the newbornis increased comparedto those who have a

successful VBAC.



SECTION


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CONTRAINDICATIONS TO VAGINAL

BIRTH AFTER CAESAREAN SECTION

1. Previous classical or invertedT uterine scar.

2. Previous hysterotomy ormyomectomy entering theuterine cavity.

3. Previous uterine rupture.

4. The presence of a

contraindication to labour, such

PLANNING A TRIAL OF LABOUR


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PLANNING A TRIAL OF LABOUR

AFTER

CAESAREAN SECTION

The woman and her

health-care provider mustdecide together whetheran appropriate situationexists for considering aTOL after Caesarean.


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DOCUMENTATION OF PREVIOUS

UTERINE INCISION

Documentation of the

location and type ofuterine incision

used during theprevious C.S. is ideal.


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In most cases, this informationcan be obtained by reviewing theoperative record from theprevious surgery.

Other information in this record,

such as the indication for theCaesarean section and theopinion of the previous surgeon,


UTERINE INCISION


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The fact that the record has beenreviewed and that no

contraindications to a TOL afterCaesarean are present should bedocumented clearly on the

prenatal record.If the record is not available, the

scar is considered unknown.


UTERINE INCISION

FACILITIES AND


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FACILITIES AND

RESOURCES

A trial of labour after Caesareanis always associated with a risk ofuterine rupture, however small.

For this reason, a TOL afterCaesarean should only be

considered in a hospital whereprovisions for performing animmediate Caesarean section are

available.


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Facilities providing VBACshould have a policy in

place to manage suchladies so that all resources

are mobilized promptly ifan intrapartum emergencyoccurs.

FACILITIES AND

RESOURCES


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Women who live in areaswhere local hospitals cannot

offer immediate C.S. shouldbe offered the opportunity for

transfer to a facility where

this service is available, inorder to permit a TOL after

Caesarean.

FACILITIES AND

RESOURCES


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The members of the teamwho could be called urgently

in the case of an intrapartumcomplication (anaesthesia,

pediatric, and obstetric

services) should be notifiedthat the woman is in hospital

and in labour and their

FACILITIES AND RESOURCES


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MATERNAL MONITORING

The woman planning a TOL afterCaesarean should have appropriatemonitoring in labour.

Progress of labour should beassessed frequently as there is someevidence that prolonged labour isassociated with an increased risk offailure and uterine rupture.

Epidural analgesia is not


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FETAL MONITORING

Continuous electronic fetalmonitoring in labour isrecommended for all womenattempting a TOL after Caesarean.

The most reliable first sign of uterine

rupture is a non-reassuring fetalheart tracing.

This may be sudden in onset and

may not be related to contractions.


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POSTPARTUM

EVALUATION

Routine digital

exploration of theCaesarean section scarpostpartum is notnecessary, except when

signs or symptoms

su est uterine ru ture


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UTERINE RUPTURE

Defined as completeseparation of the

myometrium with or withoutextrusion of the fetal parts

into the maternal peritoneal

cavity requiring emergencyCaesarean delivery or

postpartum laparotomy.


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It is an uncommoncomplication of VBAC,

but is associated withsignificant maternal and

perinatal morbidity andmortality.

UTERINE RUPTURE


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The most common

sign or symptom ofuterine rupture is

non-reassuring fetal heart

rate monitoring

UTERINE RUPTURE


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Other clinical signs include :

2. Cessation of contractions,

3. Loss of the presenting part onvaginal examination,

4. Abdominal pain,

5. Vaginal bleeding,6. Hematuria, or

7. Maternal cardiovascular

instability.

UTERINE RUPTURE


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The type and

location of theprevious uterineincision helps to

determine the risk ofuterine rupture.

UTERINE RUPTURE

UTERINE RUPTURE INCIDENCE


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0.2% to 1.5% in a woman whoattempts labour after a transverselower-uterine-segment incision and

1% to 1.6% after a vertical incisionin the lower uterine segment.

4% to 9% with a classical or T

incision; and for this reason, a TOLafter Caesarean is contraindicatedin these situations.

UTERINE RUPTURE INCIDENCE


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The relative risk of: uterine rupture, maternal morbidity, and perinatal mortality or severe

morbidity

is increased in thoseundergoing a TOL afterCaesarean compared to ERCS,

but that the absolute risk

UTERINE RUPTURE

UTERINE RUPTURE


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The treatment ofsuspected uterine ruptureis immediate laparotomy

after maternal stabilizationand anaesthesia.

Once the fetus isdelivered, maternal

hemorrhage must be

UTERINE RUPTURE


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In 1996, Rozenberg et al.examined

ultrasonographicmeasurement of the lower

uterine segmentsmyometrial thickness 36to 38 weeks gestation as

a predictor of uterine

UTERINE RUPTURE


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If the lower segmentthickness was less than 3.5

mm, the risk of uterinerupture or dehiscence was

11.8%; and themeasurement was greaterthan 3.5 mm, the risk of

UTERINE RUPTURE


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In a follow-up open study,Rozenberg et al. found

that the use of the lower-uterine-segment

measurement helpedclinicians select women fora TOL after Caesarean.

UTERINE RUPTURE


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OXYTOCICS AND

TRIAL OF LABOUR AFTERCAESAREAN SECTION


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Zelop et al. supported

the same conclusionabout the risk of uterinerupture with

augmentation in a 1999study .

AUGMENTATION

AUGMENTATION


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Goetzl et al. examined therelationship between the dose ofoxytocin used and the risk of

uterine rupture in womenundergoing a TOL afterCaesarean.

No significant association wasdetected between exposure to

oxytocin and the risk of uterine

AUGMENTATION


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Careful surveillance of the womanfor progress of labour is required,especially when the diagnosis ofdystocia is being considered.

There are insufficient studies

examining the use of other agents toaugment labour, such asprostaglandins, and their safety in a

TOL after Caesarean.

AUGMENTATION

INDUCTION


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INDUCTION

In 2000, Ravasia et al. reviewed the risk

of uterine rupture in women undergoingan induction TOL after Caesarean.

In 575 women with a previous

Caesarean section, labour was inducedwith:

3. Prostaglandin E2 gel ,

4. Intracervical foley catheter , or5. Amniotomy and/or oxytocin .

Outcomes were compared to those

women undergoing a TOL with

INDUCTION


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The risk of uterine rupture wasnot increased in those who

underwent either

amniotomy/oxytocin or foleycatheter induction,

but was significantly increasedin those who underwent aprostaglandin E2 induction .

INDUCTION


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INDUCTION


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In 2003, Delaney and Young reported

the examination of3746 women with aprior Caesarean delivery who underwenteither induced or spontaneous labour.

They found that induced labour wasassociated with a greater risk of :

Early postpartum hemorrhage(7.3% vs. 5.0%),

Caesarean delivery(37.5% vs. 24.2%), and

Admission to a neonatal intensive care

unit (13.3% vs. 9.4%).

INDUCTION


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There was a trendtowards a higher rate ofuterine rupture, but this

was not statistically

significant (0.7% vs.0.3%).

INDUCTION

INDUCTION


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In another retrospective studyof560 women, the rate ofuterine rupture in women

whose labour was inducedwith :

Oxytocin was 2%,with

Prostaglandin was 2 9%

INDUCTION


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Up to 2001, there was conflictingdata on the risk of induction of

labour with prostaglandin E2.Several other smaller studies

reported that it appeared to besafe, effective, and notassociated with an increased risk

of uterine rupture.

INDUCTION

INDUCTION


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In the largest study published todate, conducted by Lydon-Rochelle et al., the incidence ofuterine rupture was reviewed

retrospectively in 20 095women with a previous C.S. andreported as follows:

Elective repeat C.S. (no labour)0.16%;

Spontaneous labour 0.52% ; Labour induced without

INDUCTION

INDUCTION


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The possibility that the use of oxytocinand/or prostaglandin for induction oflabour in women considering a TOL afterCaesarean may be associated with an

increased risk of uterine rupture and itssequelae must be discussed with thepatient.

The absolute risks of uterine rupture arelow, but the relative risks (especially withthe use of prostaglandin E2 compared to

spontaneous labour) are greater.

INDUCTION

MISOPROSTOL


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MISOPROSTOL

Misoprostol has been proposed as an

effective and economical agent forcervical ripening and induction.

In 1998, Sciscione et al. reported a case

of uterine rupture in a woman with 2previous Caesarean sections aftermisoprostol was administered as a

cervical ripening agent.A number of small series reported a risk

of uterine rupture from 0% to 11.7% withmisoprostol in women undergoing a TOL

MISOPROSTOL


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Blanchette et al. compared

prostaglandin E2 to misoprostol inwomen undergoing induction TOLafter Caesarean and found them tobe equally effective,

But misoprostol was associated with

a higher incidence of uterine rupture(18.8% compared to no ruptures inthe prostaglandin E2 group).

The numbers in all of these studies

MISOPROSTOL


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Until further randomizedstudies are completed,

misoprostol should bediscouraged as a method

of induction or cervicalripening in women withprevious Caesarean

MISOPROSTOL

CERVICAL PREPARATION


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In situations where delivery is indicated

and the cervix is unfavourable, a TOLafter Caesarean can be considered.

In a cohort study published in 2002,

Ben-Aroya et al. compared womenundergoing a trial of labour afterCaesarean section in 3 situations:

Spontaneous labour (n=1432), Prostaglandin cervical ripening (n=55),

and

Cervical ripening by foley catheter



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There was a significantly higherrate of dystocia (30.4% vs.11.6%) and repeat Caesarean

sectionin the second stage(49.1% vs. 35.2%) in the foleycatheter group compared to the

control group.There was no difference in the

rate of uterine rupture fetal



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In a Canadian study published in2004, Bujold et al. compared therate of uterine rupture in 1807women who presented inspontaneous labour,

417 induced with amniotomy withor without oxytocin, and

255 induced with transcervical

foley catheter.




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The rate of successful vaginal birthwas :

78% in the spontaneous group,

77.9% in the amniotomy group, and 55.7% in the transcervical foley

group .

However, the rates of uterinerupture did not differ significantly:

1.1%, 1.2%, and 1.6%,



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These data support theuse of the foley catheter

for cervical ripening ofan unfavourable cervix

in women undergoing aTOL after Caesarean.



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SPECIAL

CIRCUMSTANCES

MORE THAN ONE PREVIOUS LOW


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.TRANSVERSE C.S

Several authors have assessedthe rate ofsuccessful VBAC andrisk ofuterine rupture in women

with more than one previous lowtransverse Caesarean section.

All indicated success ratesbetween 62% and 89%, anduterine rupture rates between



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Unfortunately, the use ofprostaglandins or oxytocin forinduction or augmentation was not

considered.Caughey et al. reported a uterine

rupture rate of 3.7% versus 0.8% in aretrospective review of 134 womenundergoing labour after 2 previous

Caesarean sections.


.TRANSVERSE C.S



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In the largest study, Miller et al.demonstrated :

A VBAC success rate of 75.3% in1827 women with 2 or moreprevious low transverse

Caesarean sections withA uterine rupture rate of 1.7%

vs. 0.6% in the ERCS group.

TRANSVERSE

CAESAREAN SECTION

MULTIPLE PREGNANCY


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MULTIPLE PREGNANCY

Seven studies have examined atotal of 233 women attemptingVBAC in multiple pregnancy.

All support a trial of VBAC inmultiple pregnancy as being safeand effective,

With success rates of69% to84%, and without increased

maternal or fetal morbidity or

MULTIPLE PREGNANCY


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In one study, uterine dehiscence wasnoted in 1 woman on manualexploration after successful vaginaldelivery of both twins, and notreatment was required.

Each of these studies examined a

small number of women, however;and greater numbers would berequired to detect rare outcomes

such as uterine rupture and maternal

MULTIPLE PREGNANCY

BREECH PRESENTATION


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BREECH PRESENTATION

A large multicentre trial by Hannahet al. demonstrated that a plannedCaesarean birth is associated withbetter perinatal and neonataloutcomes in breech presentation atterm.

This recommendation has beenadopted by the SOGC and wouldtherefore preclude a planned TOL

after Caesarean in women


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External cephalic

version is notcontraindicated in a

woman with aprevious Caesarean

BREECH PRESENTATION

DIABETES MELLITUS


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Coleman et al. examined 156women with GDM and planned

TOL after Caesarean and

compared them to non-GDMwomen attempting TOL afterCaesarean.

They reported that the successrate for VBAC of 64.1% in women

with GDM was lower than the

DIABETES MELLITUS


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A retrospective study of TOL afterCaesarean in women with pre-gestational or gestationaldiabetes found similar results.

Based on these studies,

diabetes mellitus should not beconsidered a contraindication toTOL after Caesarean.

DIABETES MELLITUS

MACROSOMIA


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In a study examining the

outcome of365 women whounderwent a TOL after

Caesarean, giving birth toneonates weighing more than4000 g, Zelop et al.

demonstrated asuccess rate of 60%, withno increase in maternal or fetal

MACROSOMIA


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In 2003, Elkousy et al. reported an

examination of9960 women with aprevious C.S. planning a trial oflabour further stratified by neonatalbirth weights and birth history.

His results indicate that the

likelihood of successful VBACdecreases with increasing birthweight and is lowest in those who

have never had a successful vaginal

MACROSOMIA


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Based on these results,suspected macrosomia is

not a contraindication to aTOL after Caesarean,although it may be

associated with a lowerchance of success.

MACROSOMIA

INTERDELIVERY INTERVAL


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Four studies haveexamined the

relationship betweenthe inter-delivery

interval and the rate ofsuccessful VBAC and

uterine rupture



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Esposito et al. examined 23 cases ofuterine rupture and compared themto 127 controls.

There was an increased risk ofuterine rupture with a shortinterpregnancy interval

(


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Shipp et al. reviewed 311 womenwho underwent a TOL afterCaesarean less than 18 months after

their Caesarean section andcompared them to 2098 women whounderwent a TOL after Caesarean

after more than 18 months.The shorter interval was associated

with a 3-fold increase in the

risk of uterine rupture (2 25% vs




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In 2002, Bujold et al.reported an observational

study of 1527 womenundergoing a planned TOL

after Caesarean atdifferent intervals from the

index Caesarean delivery




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The rates of uterine rupturewere as follows:

36 months, 1%.


POSTDATISM


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OS S

Three studies have examinedpostdatism and TOL afterCaesarean.

Success rates for VBACafter 40 weeks were

reported from 65% to 73%and were comparable to

success rates for women

POSTDATISM


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Zelop et al. reported that therisk of uterine rupture in a

TOL after Caesarean after 40

weeks was not significantlyincreased when compared to

those who delivered before 40weeks, whether inspontaneous labour or after

ONE- VERSUS TWO-LAYER CLOSUREOF LOW TRANSVERSE


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OF LOW TRANSVERSE

CAESAREAN SECTION

In 1992, Hauth et al. published datacomparing :

Operative time, Endometritis,Transfusion, and Placement of extra hemostatic

sutures in women undergoinguterine closure in 1 layer comparedto 2 layers.

ONE- VERSUS TWO-LAYER CLOSUREOF LOW TRANSVERSE


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The only significant difference was inoperative time:

44 minutes with 1-layer

compared to 48minutes with 2-layer closure.

Similar findings were published byOhel et al. in 1996.

The trend shifted in many centres

towards single-layer closure

OF LOW TRANSVERSE

CAESAREAN SECTION

ONE- VERSUS TWO-LAYER CLOSURE OFLOW


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In 1997, Chapman et al. publisheda review of 145 women whounderwent a TOL after Caesarean

after being randomized to either 1-layer or 2-layer closure in theprevious Caesarean section.

They reported no significantdifference in the outcome of the

next pregnancy

LOW

TRANSVERSE CAESAREAN SECTION

- -LOW


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In a 2002 review of 2142 womenwho underwent a TOL afterCaesarean, Bujold et al. noted that

a 1-layer interlocking closure wasassociated with an increased risk ofuterine rupture when compared to a

2-layer closure (3.1% vs.0.5%).

Further study in this area is

TRANSVERSE CAESAREAN SECTION

UNKNOWN SCAR


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All records available or obtainable

describing the womans previous C.S.should be reviewed.

If unavailable, information about thecircumstances of the C.S. will helpdetermine the likelihood of a verticaluterine incision.

The majority of unknown scars willbe lower transverse incisions (92%)

and therefore at low risk for uterine

UNKNOWN SCAR


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If the history suggests a reasonablelikelihood of a classical incision, itwould be prudent to recommend arepeat C.S. ,

But in settings where the history

indicates a high likelihood of lowertransverse uterine incision and thewoman wishes to proceed after

counselling a TOL after

UNKNOWN SCAR

OTHER FACTORS


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Factors such as :

2. Maternal obesity,

3. The presence of postpartum fever afterCaesarean section,

4. Type of suture material,

5. Mllerian duct anomalies, and

6. Maternal age andTheir relationship to the risk of uterine

rupture have been examined in small

studies, but definitive conclusions

:Recommendations:Recommendations


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:Recommendations

Provided there are noProvided there are nocontraindications, a womancontraindications, a woman

with one previous transversewith one previous transverse

L.S.C.S. should be offered aL.S.C.S. should be offered a

trial of labour after C.S. withtrial of labour after C.S. with

appropriate discussion ofappropriate discussion ofmaternal and perinatal risksmaternal and perinatal risks

and benefitsand benefits.)II-2B()II-2B(


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The intention of a womanThe intention of a woman

undergoing a TOL after C.S.undergoing a TOL after C.S.

should be clearly stated andshould be clearly stated anddocumentation of the previousdocumentation of the previous

uterine scar should be clearlyuterine scar should be clearly

marked on the prenatalmarked on the prenatalrecord.record.


)II-2B()II-2B(



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For a safe labour afterFor a safe labour after

C.S. , the woman shouldC.S. , the woman should

deliver in a hospitaldeliver in a hospitalwhere an immediatewhere an immediate C.S.C.S.

is available.is available.


)II-2A()II-2A(



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The woman and her health-The woman and her health-care provider must be awarecare provider must be aware

of the hospital resources andof the hospital resources andthe availability of obstetric,the availability of obstetric,

anaesthesia, pediatric, andanaesthesia, pediatric, and

operating-room staff.operating-room staff.


)II-2A()II-2A(



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Each hospital should have aEach hospital should have awritten policy in placewritten policy in place

regarding the notificationregarding the notificationand/or consultation for theand/or consultation for the

physicians responsible for aphysicians responsible for a

possible immediatepossible immediate C.S.C.S.


)III B()III B(



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Continuous electronicContinuous electronic

fetal monitoring offetal monitoring of

women attempting awomen attempting aTOL afterTOL after C.S.C.S. isis

recommended.recommended.


)II-2A()II-2A(



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Suspected uterine ruptureSuspected uterine rupturerequires urgent attentionrequires urgent attention

and expedited laparotomyand expedited laparotomyin order to attempt toin order to attempt to

decrease maternal anddecrease maternal and

perinatal morbidity andperinatal morbidity and

mortality.mortality.


)II-2A()II-2A(



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OxytocinOxytocinaugmentation is notaugmentation is not

contraindicated incontraindicated inwomen undergoing awomen undergoing a

TOL afterTOL after C.S.C.S.


)II-2A()II-2A(



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Medical induction of labourMedical induction of labourwith oxytocin may bewith oxytocin may be

associated with anassociated with anincreased risk of uterineincreased risk of uterine

rupture and should be usedrupture and should be used

carefully after appropriatecarefully after appropriate

counselling.counselling.


)II-2B()II-2B(



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Medical induction of labourMedical induction of labourwith prostaglandin E2with prostaglandin E2

(dinoprostone) is associated(dinoprostone) is associatedwith an increased risk ofwith an increased risk of

uterine rupture and should notuterine rupture and should not

be used except in rarebe used except in rarecircumstances aftercircumstances after

appropriate counselling.appropriate counselling.


)II-2B()II-2B(



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Prostaglandin E1Prostaglandin E1(misoprostol) is associated(misoprostol) is associated

with a high risk of uterinewith a high risk of uterinerupture and should not berupture and should not be

used as part of a TOL afterused as part of a TOL after

C.S.C.S.


)II-2A()II-2A(



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A foleys catheterA foleys cathetermay be used safely tomay be used safely to

ripen the cervix in aripen the cervix in awoman planning awoman planning a

TOL afterTOL after C.S.C.S.


)II-2A()II-2A(



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The available data suggestThe available data suggestthat a trial of labour inthat a trial of labour in

women with more than onewomen with more than oneprevious C.S.previous C.S.is likely to beis likely to besuccessful but is associatedsuccessful but is associated

with a higher risk of uterinewith a higher risk of uterinerupture.rupture.


)II-2B()II-2B(



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Multiple gestation isMultiple gestation is

not a contraindicationnot a contraindicationto a TOL afterto a TOL after

Caesarean.Caesarean.


)II-2B()II-2B(



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Diabetes mellitusDiabetes mellitusis not ais not a

contraindication tocontraindication toTOL after C.S.TOL after C.S.


(II-2B)(II-2B)



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Suspected fetalSuspected fetal

macrosomia is not amacrosomia is not a

contraindication to acontraindication to a

TOL after Caesarean.TOL after Caesarean.


(II-2B)(II-2B)



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Women deliveringWomen deliveringwithin 18 to 24within 18 to 24

months of a C.S. shouldmonths of a C.S. shouldbe counseled about anbe counseled about an

increased risk of uterineincreased risk of uterinerupture in labour.rupture in labour.


(II-2B)(II-2B)



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Postdatism is notPostdatism is not

aacontraindication tocontraindication to

a TOL aftera TOL after

CaesareanCaesarean


(II-2B)(II-2B)



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Every effort should beEvery effort should bemade to obtain themade to obtain the

previous Caesarean sectionprevious Caesarean sectionoperative report tooperative report to

determine the type ofdetermine the type ofuterine incision used.uterine incision used.

(II-2B)(II-2B)



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In situations where the scar isIn situations where the scar is

unknown, informationunknown, informationconcerning the circumstances ofconcerning the circumstances of

the previous delivery is helpful inthe previous delivery is helpful indetermining the likelihood of adetermining the likelihood of a

low transverse incision.low transverse incision.

If the likelihood of a lowerIf the likelihood of a lowertransverse incision is high, TOLtransverse incision is high, TOL

after Caesarean can be offeredafter Caesarean can be offered.

(II 2B)(II 2B)


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guidelines for vaginal birth after previous caesarean birth

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