Elijah Stirling

Those providing ante-natal care to women considering vaginal birth after Caesarean section (hereafter VBAC) should discuss and record the risks relating to the pregnancy and birth, the risks and benefits of VBAC versus Caesarean section (hereafter C-section) and the planned mode of delivery.

Where the drug Syntocinon is to be employed in inducing a VBAC birth, there should be set a maximum level of infusion and a maximum period of time of administration of the drug, beyond which Consultant authorisation is required.

Accordingly, I recommend that the Pregnancy Record booklet should be amended in the section headed “Birth Plan” so as to include a new section relating specifically to women considering VBAC, to include sub-sections headed - [1] Risks relating to the pregnancy, [2] Risks and benefits of VBAC versus C-section, [3] Preference for mode of delivery. All sections should be completed by the midwife. The applicable risks should be listed at 1. The risks and benefits should be noted with the content of the discussion at 2. A tick box with a choice of VBAC or C-section would suffice for 3. Additionally, within the Ante-natal Assessment records, the obstetric team should clearly document that the following has been discussed with a woman considering VBAC - [1] Risks relating to the pregnancy, [2] Risks and benefits of VBAC versus C-section, [3] The birth plan agreed between the Consultant and the woman. Where possible this discussion should take place between the woman and the named Consultant, and the note recorded by that Consultant.

Accordingly, I recommend that a section be created in the Partogram (an example of which is found at CP 10, page 235) for the specific recording of the birth plan agreed between the Consultant and the VBAC woman, and the Consultant’s directions for the use of Syntocinon. The birth plan is likely to be a transfer of that contained in the Ante-natal Assessment records (per the foregoing section), and should be noted on the Partogram by the Consultant. If the named Consultant is not available, it should be done by the Consultant, whom failing the Registrar, on duty. It should be recorded in consultation with the woman to ensure it is accurate, and remains up to date. The section should include: [1] The agreed birth plan, [2] Where applicable, the maximum infusion of Syntocinon to be administered by the midwife, with any increase beyond that maximum requiring Consultant authorisation, and [3] Where Syntocinon is being infused, the maximum number of hours of infusion with any increase beyond that requiring Consultant authorisation.

However, in circumstances where the plan changes substantially, and in consultation with the woman, the written note of the birth plan should be altered on the Partogram, ideally by the Consultant, failing which by the Registrar on duty on the direction of the Consultant.