• The timing of delivery should be tailored to the patient.
• If history of vaginal bleeding/ other risk factors for preterm delivery- consider ‘Late preterm delivery’- 34+0 to 36 +6 weeks.
• If uncomplicated placenta previa- Consider between 36+ 0 and 37+0.

Risk of anal sphincter injury in women undergoing VBAC is 5%.

Birthweight is the strongest predictor of anal sphincter injury in women undergoing VBAC.

Antenatal treatment for vaginal or rectal colonisation does not reduce the likelihood of GBS colonisation at the time of delivery and so is not indicated in this situation.

IAP should be offered to GBS-colonised women

Planned VBAC is associated with an approximately 1 in 200 (0.5%)
risk of uterine rupture

It should be done at 32–34 weeks of gestation for women with twins.

The recommended time of testing is 3–5 weeks prior to the anticipated delivery date- therefore  35–37 weeks of gestation in singleton pregnancies with no risk factors for preterm delivery.

• No screening test is entirely accurate.
• 17% to 25% of women who have a positive swab at 35–37 weeks of gestation will be GBS negative at delivery.
•  5% to 7% of women who are GBS negative at 35–37 weeks of gestation will be GBS positive at delivery.
• Many of the babies who are severely affected from GBS infection are born prematurely, before the suggested time for screening.

The six elements considered to be reflective of good care are:
 Consultant obstetrician planning and directly supervising delivery.
 Consultant anaesthetist planning and directly supervising anaesthesia at delivery.
 Blood and blood products available.
 Multidisciplinary involvement in preoperative planning.
 Discussion and consent, including possible interventions (such as hysterectomy, leaving the placenta in situ, cell
salvage and interventional radiology).
 Local availability of a level 2 critical care bed.

According to the RCOG- Any lack of compliance with the care bundle by the clinical team for a woman with either placenta praevia or accreta
should be investigated.

According to MBBRACE-UK 2014 to 2016- Women who have had a previous caesarean section who also have either placenta praevia or an anterior placenta underlying the old caesarean section scar at 32 weeks of gestation are at increased risk of placenta accreta and should be managed as if they have placenta accreta, with appropriate preparations for surgery made.

In pregnancies<12 weeks gestation, anti-D Ig prophylaxis is only indicated following ectopic pregnancy, molar pregnancy, therapeutic termination of pregnancy and in
cases of uterine bleeding where this is repeated, heavy
or associated with abdominal pain. The minimum dose should be 250 IU. A test for fetomaternal haemorrhage (FMH) is not required

The UK National Screening Committee examined the issue of strategies recommended that routine screening using bacteriological culture or near-patient testing techniques should not be introduced into UK practice.

The US Guidelines advise that all pregnant women should be offered screening for GBS carriage at 35–37 weeks of gestation and those found to be colonised with GBS should be offered intrapartum antibiotic prophylaxis.

Methotrexate adjuvant therapy should not be used for expectant management as it is of unproven benefit and has significant adverse effects.

Successful VBAC is more likely among women with previous caesarean for
fetal malpresentation (84%) compared with women with previous caesarean for either labour dystocia (64%) or fetal distress (73%) indications.

• If the history suggests that the reaction described is not likely to be allergic in nature then penicillin should be given.
• If the history suggests an allergy to beta-lactams, but one that is not severe(i.e. no anaphylaxis, angioedema, respiratory distress or urticaria), then a cephalosporin can be administered.
• If the allergy to beta-lactams is severe then intravenous vancomycin is recommended.