Quality Statement 5: Operative Reports and Incision Type

Resources Quality Statements Advisory Committee About

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.

Background

Physicians and midwives should make every effort to obtain an operative report from the previous Caesarean section to develop an appropriate plan of care for people considering a vaginal birth after Caesarean (VBAC). Physicians and midwives should review the operative report and note the type of uterine incision used, as well as any extensions of the incision, to determine the feasibility of VBAC. A previous classical or inverted “T” uterine scar, a previous myomectomy entering the uterine cavity, or a previous uterine rupture are contraindications to labour after Caesarean.

When the operative report is unavailable, physicians and midwives should discuss and explore specific details of previous Caesarean birth(s) to determine the likelihood of a low transverse uterine incision. Considerations should include the reason for the previous Caesarean, gestational age at the time of the previous Caesarean, and any other relevant clinical details. Any other previous relevant gynecologic history—including other uterine surgeries or interventions—should be considered and documented. If the likelihood of a low transverse incision is high, labour after Caesarean can be offered with informed consent and a discussion of possible increased risks of harm due to uterine rupture. Inability to obtain the previous operative report(s) should be documented.

What This Quality Statement Means

For Pregnant People

Your physician or midwife should read the report from your previous Caesarean birth. If they don’t know the type of scar on your uterus from your previous Caesarean birth, they should help determine whether a vaginal birth after Caesarean is right for you.

For Clinicians

Obtain operative reports from previous Caesarean births whenever possible to develop an appropriate plan of care. Inability to obtain the operative record should be documented, and VBAC may still be offered with shared decision-making. Document the discussion and planned mode of birth. When the incision type used in the previous Caesarean birth is unknown, assess the person’s preference and the clinical circumstances surrounding the previous Caesarean birth to determine whether VBAC is feasible.

For Health Services

Ensure that physicians and midwives and facilities have the necessary resources, systems, and processes in place to obtain and send operative reports from previous Caesarean births in a timely way whenever possible. When the incision type used in the previous Caesarean birth is unknown, ensure that physicians and midwives are equipped with the knowledge and skills to assess the clinical circumstances surrounding previous Caesarean birth and determine whether VBAC is feasible.

Quality Indicators

Process Indicators

Percentage of pregnant people who have had a previous Caesarean birth whose physician or midwife makes a documented attempt to obtain the operative report from the previous Caesarean birth

Denominator: number of pregnant people who have had a previous Caesarean birth
Numerator: number of people in the denominator whose physician or midwife makes a documented attempt to obtain the operative report from the previous Caesarean birth
Data source: local data collection

Percentage of pregnant people who have had a previous Caesarean birth with an unknown type of uterine incision and have a documented individualized assessment to determine whether VBAC is feasible

Denominator: number of pregnant people who have had a previous Caesarean birth with an unknown type of uterine incision
Numerator: number of people in the denominator who have a documented individualized assessment to determine whether VBAC is feasible
Data source: local data collection

Definitions Used Within This Quality Statement

Uterine incision

The type of cut made to the uterus during Caesarean birth. This may be different than the incision made in the skin. Low transverse, a horizontal incision in the lower uterus, is the most common type used in Canada and has a lower risk of uterine rupture than other types of incisions.

Individualized assessment

Assessment that includes the circumstances of the previous Caesarean birth, the person’s values and preferences, the person’s risk profile, and clinical factors relevant to the current pregnancy and fetal health during labour.

Evidence to Improve Care