Subject: Intrapartum Care for Planned Vaginal Birth After Cesarean, VBAC

POLICY: VBAC Protocol for intrapartum care

GUIDELINES: 1. Prenatal records will be reviewed to assure documentation of the presence of all inclusion criteria and the lack of all exclusion criteria.

2. Prenatal records will include documentation of all required prenatal testing, counselling and signed consent form.

3. Labor stimulation techniques including nipple stimulation and herbal treatments will not be used during on VBAC women in the care of Women and Birth Care, Inc.

4. Labor that is beyond the parameters of normal as described in the Labor monitoring protocol will not continue to labor in The Birth Center but will be transferred to the hospital for continuing care.

5. Women must go into spontaneous labor between 37 weeks and 41 weeks of gestation.

5. Women planning a VBAC with Women and Birth Care, Inc. will complete an approved VBAC course prior to 37 weeks gestation or prior to onset of labor.

PROCEDURE: 1.  Prenatal records will be reviewed to assure documentation of the presence of all inclusion criteria and the lack of all exclusion criteria:

Inclusion criteria – all of the following MUST be present:

·         Only one prior low transverse cesarean section

·         Clinically adequate pelvis

·         Less than thirty minute drive to level one hospital for emergency care if needed

·         Interval between deliveries > 18 months

  Exclusion criteria – None of the following may be

  present:

·         Previous classical or T-shaped incision or unknown incision type

·         Previous extensive fundal uterine surgery or previous uterine rupture

·         More than one previous cesarean section

·         Medical or obstetric complications that preclude a safe vaginal delivery

·         Diagnosed macrosomia

·         Inadequate pelvis

·         Uncontrolled gestational diabetes

·         Gestation <37 weeks or greater than 41 weeks at onset of labor

2. Prenatal records will include documentation of all required prenatal testing and counselling including the following:

·         Prior cesarean birth records documenting the type of surgical incision and repair.

·         Prenatal counselling about the potential benefits, risks and alternatives to a VBAC.

·         Maternal receipt of the following documents:

·         A complete obstetrical ultrasound to determine placental placement.

·         Signed consent form and VBAC checklist in chart with approval of Clinical Director.

·         Maternal attendance at an approved VBAC course.

3. Labor will not be stimulated by mechanical or chemical means – labor must start spontaneously.  There will be no use of nipple stimulation, herbal techniques or use of castor oil for labor enhancement.

4. Although there is no proven predictor of uterine rupture, a transfer to a Level one hospital will be necessary if at any time during the labor any of the following present:

·         Severe abdominal pain, especially if persisting between contractions

·         Chest pain or shoulder tip pain, sudden onset of shortness of breath

·         Acute onset scar tenderness

·         Abnormal vaginal bleeding or hematuria

·         Cessation of previously efficient uterine activity

·         Maternal tachycardia, hypotension or shock

·         Loss of station of the presenting part, suspected malposition of fetus with dysfunctional labor.

·         Fetal bradycardia or abnormal FHT’s

5. Labor will adhere to the strict protocols of labor monitoring as described in the labor management protocol including:

Maternal vital signs (VS) will be monitored as

follows:

·         Complete set of VS at admission

·         Repeat complete set of VS Q 4 hours in labor

·         VS are to be taken at more frequent intervals if warranted and can be ordered by the midwife

·         Maternal pain is to closely monitored for signs of placental separation or scar separation.

Fetal Heart Tones (FHT’s) are to be monitored as

follows: (fetal heart rate abnormality is the first sign

of uterine rupture in 70% of cases)

·         at admission and is to include:

o   monitoring during a contraction

o   through the peak of the contraction

o   continuing until at least 15 seconds past the contraction in order to ascertain fetal tolerance of labor.

·         In active labor FHT’s are to be monitored, at a minimum, every 30 minutes:

o   At least every hour the monitoring is to include:

§  monitoring during a contraction

§  through the peak of the contraction

§  continuing until at least 15 seconds past the contraction in order to ascertain fetal tolerance of labor.

·         During second stage FHT’s are to be monitored, at a minimum, every 5 minutes:  

o   at least every 30 minutes monitoring will include:

§  monitoring during a contraction

§  through the peak of the contraction

§  continuing until at least 15 seconds past the contraction in order to ascertain fetal tolerance of second stage labor

  1. American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Aug. 14 p. (ACOG practice bulletin; no. 115). [136 references]
  2. Royal College of Obstetricians and Gynaecologists (RCOG). Birth after previous caesarean birth. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2007 Feb. 17 p. (Green-top guideline; no. 45). [116 references]

3.       http://www.midwiferytoday.com/articles/vbacprimer.asp, A VBAC Primer: Technical Issues for Midwives. by Heidi Rinehart, MD, © 2001 Midwifery Today, Inc. All rights reserved.

4.       https://kr.ihc.com/ext/Dcmnt?ncid=520869553  Vaginal Birth After Cesarean (VBAC), 2011 update. This care process model (CPM) was developed by clinical experts from Intermountain Healthcare’s Women and Newborns Clinical Program based on the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Number 115 and Guidelines for Perinatal Care, Sixth Edition.