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Next Birth After Cesarean - what the King Edward memorial Hospital have on offer

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Thoughts & musings on midwifery related topics for the April Education Newsletter. 

King Edward Memorial Hospital - Next Birth after Cesarean Clinic


Back in 2009 I first heard about the Next Birth After Caesarean Clinic at the ACM National Conference held in Adelaide.  I remember thinking - why don’t we have something like this in all hospitals where antenatal care and birthing takes place - especially as the rate of caesarean births was on the rise?  I know it is still in practice and going strong and so we invited the team to share with us something about their service and what they have been up to.  Maybe it will spark some interest amongst midwives around Australia where there are not similar services - but there is a need - to reach out to the King Edward Memorial Hospital and ask for their assistance...

The Next Birth After Caesarean Clinic (NBAC) began in July 2008 as a midwifery led antenatal clinic. The aims were to improve the care and information offered to women and their families who have experienced a Caesarean Section (C.S).

The clinic promotes informed choice thus empowering women and their families to make informed decisions and the women decide on the mode of birth.

The World Health Organisation suggests that 72 to 75% of women pursuing a VBAC should be successful. (Royal College of Obstetricians and Gynaecologists. Birth After Previous Caesarean Birth. Green-top Guideline No 45. 2015)

A small team of passionate midwives run the clinic, enabling the women to get to know the midwives during the pregnancy. The NBAC clinic is available to woman who has had one or more previous C.S and resides in the King Edward catchment area. Those women that seek a vaginal birth after a caesarean (VBAC) that are unable to have at their base hospital may birth at King Edward.  NBAC clinics are now starting at Fiona Stanley in the south metropolitan area and at SJOG Midland in the east.

Antenatal Care in NBAC Clinic

  • First visit 14~16 weeks with a midwife
  • Previous births are noted and debriefing may be required. If the client has birthed elsewhere we obtain the notes and are able debrief at another time.  Our booking visits are longer specifically for this reason.
  • Written information on both VBAC and CS - risks and benefits are discussed 
  • Education sessions: VBAC or Planned CS are encouraged
  • Collaboration between professions (psychology, dietician etc)
  • Doctors clinic at  24, 36 and 40 weeks
  • Consent form signed with consultant at 36/40 and the Management Plan for Women in Labour is completed.
  • Routine antenatal care (bloods, ultrasounds etc)
  • Stretch and sweeps from 39/40 weeks if woman interested. 

Postnatal Care

  • Post birth women are visited on the ward or telephoned at home.
  • Feedback regarding care is predominantly positive for both VBAC and NELUSCS.
  • NBAC packs are sent out to all appropriate women following their first Caesarean.

Pro’s and Con’s of the NBAC Clinic

Pro’s

  • Evidence based information,
  • Staff – Empowering women and their families to make informed decicions
  • caring, helpful, positive, consistent advice, encouraging and accommodating
  • Low risk clinic so minimal doctor visits.
  • Shorter wait times in clinic, continuity of carer in clinic

Con’s

  • The NBAC midwives do not follow the women though the labour and birth.
  • We do not have a specific doctor for our clinic.

About the NBAC Clinic

Total births for the clinic for 2017: 167

VBAC success rate in NBAC clinic is 57% for 2017 (not including ELUSCS) - (53 out of 93 births resulted in a VBAC).

Overall births:

  • 31.7% VBAC
  • 44% ELUSCS
  • 23.95% NELUSCS


Quarter 1 PROJECT 2016
NBAC Clinic Outcomes of women having had 2 previous caesarean births.  A total of 94 women planning a vaginal birth after 2 previous caesarean sections (VBA2C) were included in the sample group.

Of these women: 

  • 33 achieved their planned VBA2C (35.1%)
  • 33 required a NELUSCS (35.1%) and 
  • 28 chose an ELUSCS ( 29.8%)
     

Of the 66 women that attempted a VBA2C 33 achieved their planned VBA2C (therefore an overall percentage of 50%) .  The findings from collating the data indicate the main reason for a NELUSCS in our sample group as being a delay in first stage, with 24 women out of the 33 needing a caesarean section for this reason (72%

Further reasons include:

  • Fetal distress 5/33 (15%)
  • Failed IOL 2/33 (6%)
  • Breech presentation 1/33 (3%)
  • Constant scar pain 1/33 (3%)

We also explored the reasons that women changed their minds and decided on an ELUSCS rather than their planned VBA2C at booking.

Some of these include:

  • personal choice (ie partners leave issues);
  • postdates with no commencement of labour;
  • PROM, fear of big baby (previous shoulder dystocia); and
  • a diagnosed kidney problem in fetus. 

Within our sample group two women had a uterine rupture (3%) One of these ladies (#9) had a non-standard management plan in place and was experiencing constant scar pain at 41.5/40. Baby was delivered by NELUSCS with Apgar’s of 9:9 at 4085g. The other woman (#12) required a CS during labour due to a non-reassuring CTG trace however the baby was born with Apgar’s 9:9 at 3860g. 
 

 

 


Managing your CPD and linking it to learning about Caesarean birth

REFLECT: Using the ACM Reflective Activity template, take a look at your practice and current knowledge in regards to cesarean births and then birthing after a cesarean and also the practice of where you work.  Is there a policy in place?  Does your hospital have a VBAC clinic?  If not what might be needed, or who might you contact to look at establishing one? 

TAKE ACTION: Once you have a base line on your knowledge then perhaps WATCH one of our webinar recordings such as Support Vaginal Birth after Cesarean by thinking outside the box, or the Working with Birth in Theatre, or READ some resources, research or articles - there are a variety that have been published in the ACM's International Peer Reviewed Journal - Women & Birth; or think about working with your consumers (women) and your hospital to determine whether a VBAC service could be established (maybe reach out to the King Edward Memorial Hospital team for some advice or support);

ASSESS & REVIEW: Then when you have completed your continuous professional development activities don’t forget to go back to wrap up your learning by REFLECTING on all that you have addressed and learnt and consider how this might change your practice.  If you are a member you can do this in your MidPLUS portfolio, or you may just want to use a template or another resource.

ACM Resources and information for your CPD

  • You can access information about ACM webinars here
  • You can check out our recordings available in our shop
  • Or you might want to book into one of our upcoming webinars for this year in Our Events
  • Information about ACM Reflective Activities (and why we think they are important) can be found here 
  • Information on MidPLUS can be found here.  If you want to record your activities you must log into your member portal first. And MidPLUS resources can be found here.

About ACM Webinars

We have a new one every month.  If you want a particular topic addressed or you know of a fabulous presenter, please let us know at education@midives.org.au and we will do our best to incorporate your suggestion into our future schedule.

AND for ACM members ALL webinars are now free to access.  That is over $3000 value for our webinar library and $300 per year for our live webinars (so over 70 hours of CPD all for the cost of your membership).  

Know someone who is not a member that might be interested?  Get them to join and they too can access all of this CPD goodness with you - Join here