Vaginal Birth After Caesarean (VBAC)

Care for People Who Have Had a Caesarean Birth and Are Planning Their Next Birth

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Access to Vaginal Birth After Caesarean
People who have had a Caesarean birth before can plan a vaginal birth for their next birth, as long as there is no medical reason not to have one.

Quality Statement 2: Discussion After Caesarean Birth
After a Caesarean birth, people have a discussion with their physician or midwife and receive written information about the reasons for their Caesarean birth and their options for future births.

Quality Statement 3: Shared Decision-Making
Pregnant people who have had a previous Caesarean birth participate in shared decision-making with their physician or midwife. The discussion and planned mode of birth is documented in the perinatal record.

Quality Statement 4: Previous Vaginal Birth
Pregnant people who have had both a previous Caesarean birth and a previous vaginal birth are informed that they have a high likelihood of successful vaginal birth if no contraindication is present.

Quality Statement 5: Operative Reports and Incision Type
Physicians and midwives obtain an operative report from any previous Caesarean births whenever possible. Pregnant people who have had a previous Caesarean birth with an unknown type of uterine incision have an individualized assessment by their physician or midwife to determine the likelihood of a low transverse incision.

Quality Statement 6: Timely Access to Caesarean Birth
Pregnant people planning a vaginal birth after Caesarean are aware of the resources available and not available at their planned place of birth, including physician, midwifery, nursing, anesthesiology, and neonatal care, and the ability to provide timely access to Caesarean birth.

Quality Statement 7: Unplanned Labour
Pregnant people planning an elective repeat Caesarean section should have a documented discussion with their physician or midwife about the feasibility of vaginal birth after Caesarean if they go into unplanned labour. This discussion should take place during antenatal care and again if the person arrives at the hospital in labour.

Quality Statement 8: Induction and Augmentation of Labour
Pregnant people who have had a previous Caesarean birth are offered induction and/or oxytocin augmentation of labour when medically indicated, and are informed by their physician or midwife about the potential benefits and harms associated with the method proposed. Discussion about this should begin in the antenatal period.

Quality Statement 9: Signs and Symptoms of Uterine Rupture
During active labour, pregnant people who have had a previous Caesarean birth are closely monitored for signs or symptoms of uterine rupture.

Resources Quality Statements Advisory Committee About

Summary

The Provincial Council for Maternal and Child Health and Health Quality Ontario collaborated on the development of this quality standard.

This quality standard addresses care for people who have had a Caesarean birth and are planning their next birth. It focuses on care for people who are pregnant with one baby who is head-down and at full term. The primary goals of this quality standard are to improve access to safe vaginal birth after Caesarean delivery and promote informed shared decision-making. Achieving these objectives is also expected to increase Ontario’s rate of planned vaginal births after Caesarean over time.

Scope of This Quality Standard

The scope of this quality standard extends from postpartum counselling after a Caesarean birth through antenatal and intrapartum care during the next pregnancy and birth.

The guidance provided in this quality standard on pregnancy care focuses on people with a previous Caesarean birth who are pregnant with one baby that is head-down and at full term (>37 weeks), who are receiving pregnancy care from any type of health care professional. People with more than one previous Caesarean birth are included in the scope; however, research evidence is limited for this population. Careful individualized assessment and clinical judgment as part of shared decision-making is essential in this situation.

This standard does not apply to people who have the following contraindications to vaginal birth after Caesarean (VBAC):

Previous classical or inverted “T” uterine scar
Previous hysterotomy or myomectomy entering the uterine cavity
Previous uterine rupture
Placenta accreta
Placenta increta
Placenta percreta
Placenta previa
Any other maternal or fetal complication that is a contraindication to vaginal birth

Why This Quality Standard Is Needed

The primary goals of this quality standard are to improve access to safe VBAC and promote informed shared decision-making. Most people who have had a Caesarean birth can have a VBAC, and a large body of evidence suggests that VBAC is safe for most eligible pregnant people. However, Ontario’s VBAC rates have decreased over time. In the 2014/2015 fiscal year, the rate of repeat Caesarean births for Ontario was 83.3%. Repeat Caesarean births represent about one-third of Caesarean births in total (Better Outcomes Registry and Network, June 2016), suggesting that increasing Ontario’s VBAC rate could also substantially reduce the overall provincial Caesarean birth rate.

People considering planned VBAC need to balance the overall benefits (such as faster recovery time, lower risk of abnormal placentation with future pregnancy, and reduced neonatal respiratory morbidity) with the potential harms (such as uterine rupture, which occurs in approximately 1 of 200 labours after Caesarean). Overall, the available evidence suggests that both VBAC and elective repeat Caesarean section can be performed safely, and, for large populations, any absolute differences in maternal and neonatal outcomes are likely to be small. Informed shared decision-making is therefore especially important so that pregnant people can receive the care that is most consistent with their values and preferences.

There is significant variation in rates of planned VBAC across regions in Ontario; this variation may be related to regional differences in the resources available where the birth is planned: smaller and less-resourced hospitals have lower VBAC rates overall (Better Outcomes Registry and Network, June 2016). In areas that cannot offer timely access to Caesarean birth, choices for planned VBAC may be more limited. Decisions may also be influenced by social, financial, or cultural factors. Birth preferences may develop between pregnancies, and pregnant people may be influenced more by previous birth experience or by information from peers and the Internet than by health care professionals. Research has also found substantial variation among regions and institutions in the use of shared decision-making between clinicians and patients who are planning their next birth.

This quality standard is designed to help ensure that all people in Ontario who plan a birth after a Caesarean are offered VBAC, and that hospitals support and provide VBAC, when appropriate as part of high-quality, evidence-based care.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect and equity.

Pregnant people who have had a previous Caesarean birth should receive services that are respectful of their rights, and that promote shared decision-making.

Pregnant people who have had a previous Caesarean birth are provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, and religious background), and disability. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, in predominantly English-speaking settings, services should be actively offered in French and other languages.

Care providers should be aware of the historical context of the lives of Canada’s Indigenous peoples and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

A high-quality health system is one that provides good access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

How Success Can Be Measured

A limited number of overarching objectives are set for this quality standard; these objectives have been mapped to indicators to measure the success of this quality standard as a whole:

Percentage of eligible pregnant people who plan a VBAC
Percentage of eligible pregnant people who have a VBAC
Percentage of eligible pregnant people who plan an elective repeat Caesarean section

The following are intended as balancing measures to ensure that VBAC continues to be a safe option for people planning a pregnancy after a previous Caesarean section:

Rate of uterine rupture per 1,000 planned VBACs
Percentage of neonates who remain in the neonatal intensive care unit for >4 hours among those born to people who planned a VBAC compared with those born to people who planned an elective repeat Caesarean section
Rate of neonatal morbidity and mortality among those born to people who planned a VBAC compared with those born to people who planned an elective repeat Caesarean section

In addition, each quality statement within this quality standard is accompanied by one or more indicators. These indicators are intended to guide measurement of quality improvement efforts related to implementation of the statement. To assess the equitable delivery of care, the quality standard indicators can be stratified by patient or caregiver socioeconomic and demographic characteristics, such as income, education, language, and age.

What Does It Mean for Patients and Caregivers?

When it comes to childbirth, all choices come with risks and benefits. People need to know their options, and the risks and benefits of these options, so they can make the best decisions for themselves and their babies. I am currently pregnant and planning on having a vaginal birth after Caesarean (VBAC), and I am advocating for parents so they can make informed decisions and have better outcomes.

After speaking with different people and hospital administrators about informed choices in childbirth, I have found there is a range of situations and experiences that dictate how and if VBAC is offered, including where people live in the province, the culture of the hospital where they receive care, and the previous experiences of care providers. The VBAC quality standard will help create a high-quality, consistent level of care for families who may want a VBAC. It represents patient-centred care, and offers providers and families clear, research-based information that will help them make decisions based on the best available evidence. I hope this quality standard is implemented widely so that those who are giving birth after a prior Caesarean section have the information they need to make informed decisions about VBAC and have access to the care they need that reflects their values. This will help ensure the best possible health outcomes for parents and their babies.

- Céline Ouellette, panel member, Vaginal Birth After Caesarean Quality Standard Expert Panel

What Does It Mean for Providers?

I knew vaginal birth after Caesarean (VBAC) rates were low in Ontario, but I did not appreciate the significant variation in rates across the province. The implementation of this quality standard offers a great opportunity to improve the care of people considering VBAC, reducing the number of C-sections while addressing variations in care.

The quality standard will help providers have discussions about VBAC with greater confidence, and people will in turn feel empowered to engage in and direct their care. Organizations will have a vetted tool to help them support providers. The VBAC quality standard will positively inform decision-making and promote better measurable quality of care in Ontario.

- Modupe Tunde-Byass, co-chair, Vaginal Birth After Caesarean Quality Standard Expert Panel

Timeline for This Quality Standard

This quality standard was completed in April 2018.

For more information, contact QualityStandards@HQOntario.ca.

Evidence to Improve Care