The Royal College of Obstetricians and Gynaecologists (RCOG) has released an updated guideline on vaginal birth after previous cesarean (VBAC) delivery.

"Planned VBAC is appropriate for and may be offered to the majority of women with a singleton pregnancy of cephalic presentation at 37+0 weeks or beyond who have had a single previous lower segment caesarean delivery, with or without a history of previous vaginal birth," the new guidelines state.

The National Institute for Health and Care Excellence, RCOG, American College of Obstetricians and Gynecologists, and National Institutes of Health are in consensus "that planned VBAC is a clinically safe choice for the majority of women with a single previous lower segment caesarean delivery," the authors explain. "Such a strategy is also supported by health economic modelling, and would also at least limit any escalation of the caesarean delivery rate and maternal morbidity associated with multiple caesarean deliveries."

RCOG Green-top Guideline Number 45, "Birth After Previous Caesarean Birth," supersedes the previous version published in 2007. Janesh Gupta, MD, FRCOG, from the University of Birmingham, United Kingdom, and colleagues produced the guideline on behalf of RCOG.

The guideline addresses antenatal care schedule, suitability for planned VBAC, antenatal counseling, intrapartum management of planned VBAC, planning and conducting of elective repeat cesarean section (ERCS), and care of women in special circumstances such as postdates, twin gestation, fetal macrosomia, antepartum stillbirth, or maternal age of 40 years or older.

It also provides recommendations, based on lower-grade evidence, regarding which women might not be good candidates for VBAC, including, for example, those who have a history of uterine rupture or complicated uterine scars.

In England, the overall cesarean delivery rate for 2012 to 2013 was 25.5%; the majority of these deliveries were emergency (14.8%), rather than elective (10.7%), cesarean births. In the United States, the cesarean delivery rate was 31.3% in 2013, according to the American Congress of Obstetricians and Gynecologists.

New Recommendations

Evidence-based recommendations that are new to this guideline are to:

use a VBAC vs ERCS checklist or clinical care pathway to promote best practice in antenatal counseling, shared decision making, and documentation;

administer antibiotics before making the skin incision in women undergoing ERCS; and

initiate thromboprophylaxis in all women undergoing ERCS according to existing RCOG guidelines.

Important considerations in the management of women with placenta previa and previous cesarean delivery include early recognition of placenta previa, adopting a multidisciplinary approach, and informed consent.

The authors have disclosed no relevant financial relationships.

"Birth After Previous Cesarean Birth." RCOG. Published online October 1, 2015. Full text