VBAC – VAGINAL
BIRTH AFTER
CAESARIAN
Dr. Radha Nair
HOD
DEPT OF OBG
• With proper case selection, about 2/3rd (60-80%)
of these women will be eligible for trial of labor
after cesarean (TOLAC) and of these two-thirds
will deliver vaginally.
• A successful trial means a vaginal delivery of a
live fetus without scar rupture. A failed trial
means when an emergency cesarean delivery is
required or there is scar rupture.
Current Recommendations for to TOLAC
and vaginal birth after cesarean (VBAC)
1. Only one previous low segment transverse
cesarean delivery. VBAC can also be allowed in
women with previous 2 LSCS with a vaginal delivery
after counselling.
2. Clinically Pelvis should be adequate on clinical
examination.
3. No other uterine scar (e.g. hysterotomy) should be
there.
4. No previous uterine rupture should be there.
• 5. Facilities for anesthesia and cesarean for
emergency cesarean delivery should be there.
6. Availability of round the clock obstetrician for
monitoring of women in labor and for performing
emergency delivery.
7. Proper counselling of women about
advantages, disadvantages and contraindications
of vaginal delivery, risk of uterine rupture,
perinatal mortality and neonatal neurological
injury should be done.
Contraindications
1. Previous classical incision
2. Previous inverted T incision or extension of uterine
incision
3. Suspicion of cephalopelvic disproportion (CPD) or
contracted pelvis
4. Previous two LSCS without a vaginal delivery
• 5. Malpresentations
6. Medical or obstetric complications (e.g.
Placenta previa)
7. Multiple pregnancy was considered a
contraindication in the past as operative
manipulations may be needed.
However, it is no longer a contraindication as
recent studies have found low rupture rate
(0.7-1.1%) and high vaginal delivery rates
(75-85%) in them.
• 8. Patient’s refusal to undergo trial of labor.
9. Previous uterine surgeries – especially in
patient who underwent laparoscopic or abdominal
myomectomy where uterine cavity has been
breached.
Monitoring
Trial of labor (TOLAC) should only be conducted in
a well-equiped hospital with all facilities for doing
emergency cesarean section. Ideally, spontaneous
onset of labor is awaited. Labor monitoring for scar
dehiscence and for fetal surveillance (preferably
electronically) is performed. Epidural analgesia is
not contraindicated in a planned VBAC.
• 1. Induction of labor using mechanical methods
o(amniotomy or foleys catheter) is associated
with a lowerrisk of scar rupture compared with
induction using prostaglandin.
• 2. Oxytocin is allowed for augmentation of labor
(maximum dose 20-30 mu/minute).
3. Prostaglandins are used with caution.
Prostaglandin E2 gel can be used but PGE1
(misoprostol) should be avoided due to risk of
uterine rupture.
4. The pediatrician (neonatologist) should be
available at the time of delivery.
5. Any demonstration of hyperactivity of uterus
(increased frequency or intensity) or abnormality of
fetal heart sound (prolonged, late or variable
decelerations) on cardiotocography must alert the
obstetrician. If in this case the cervix is not fully
dilated, a cesarean section should be performed
immediately (within 30 minutes).
• 6. Some measure intrauterine pressure by
monitoring with a catheter (if available). Any loss
of intrauterine pressure is an indication of uterine
rupture and immediate laparotomy is indicated.
Forceps or ventouse to cut short the second
stage of labor can be used but not always
required.
7. Intrauterine exploration of the uterine scar after
vaginal delivery is not routinely performed nor
indicated.
However, if there is active bleeding, laparotomy is
advised. Otherwise, close observation of vital signs
and serial hematocrit determination is needed.
Peripartum hysterectomy may be required
Risks
1. Unsuccessful. Needing cesarean delivery
(15-20%)
2. Risk of scar dehiscence and rupture (about 0.5%)
3. Maternal morbidity and mortality is not usually
increased, but there is slightly more morbidity with
scar rupture.
• 4. Perinatal morbidity and mortality is increased
if there is scar rupture. There is risk of fetal death
and severe neurological injury including hypoxic
ischemic encephalopathy (HIE) in uterine rupture.
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