Powers & Santola · Upstate New York Birth Injury Malpractice Attorneys
Vaginal Birth After Caesarian Section (VBAC) is the term used to describe an expectant mother's attempt to have a vaginal birth after having previously delivered one or more children by C-section.
The purpose of this article is not to endorse one form of delivery over another. That is purely a personal decision. Instead, we wish to share some factors of concern that are not always discussed with patients so as to provide a different view of what relevant medical studies have reported.
For most of the 20th Century, obstetrical care providers advised their patients "once a C-section always a C-section." There was concern that a mother allowed to labor after a prior C-section bore an increased risk during that labor that the uterus could tear apart at the previous C-section surgical incision.
The C-section rate of births in this country increased from 5% to 20.8% between 1970 and 1988 and reached 24.7% in 1995. More first time (primary) cesarean deliveries set the stage for more repeat cesarean deliveries. Some estimates claim that by 1998 repeat cesarean births accounted for 1/3 of all c-sections performed.
Believing that the rate of C-sections was too high, various proposals to reduce the rate began to appear. One such approach was to actively reduce the number of repeat (elective) C-sections. The term elective is used for planned C-sections that are performed only because the mother had a previous section and not due to any other medical circumstance.
With the backing of government health organizations and medical insurance companies, the American College of Obstetricians and Gynecologists began to encourage a "trial of labor." This term describes an expectant mother's choice to try and deliver her baby vaginally, rather than by elective repeat C-section. If problems developed during the labor, the mother could always change her mind and opt for a C-section.
When discussing a "trial of labor" with an expectant mother, medical care providers often advised patients that most medical studies reported that 60-80% of all "trials of labor" after a C-section resulted in a successful vaginal birth. They also advised that VBAC avoided all risks associated with surgery (infection, anesthesia risk, blood transfusions, longer hospital stays). In addition, the mother would experience the natural birthing process. If the mother's condition was carefully monitored, a potential or developing uterine tear or rupture could be promptly identified and the child could be delivered by C-section. In theory, the overall risks associated with a VBAC were not much greater than the risks associated with a C-section. But something very important would be lacking from such an explanation of the risks of VBAC.
An often overlooked point in evaluating the risks of VBAC is that most hospitals do not have an operating room or medical staff on stand by. It takes up to 30 minutes from the time a doctor orders an emergency C-section until the surgery actually starts. This can be critical if a problem develops during a "trial of labor" and a decision to perform an emergency C-section is made. Will the expectant mother, and most importantly the baby, have 30 minutes to spare? When a uterus begins to rupture the baby's ability to receive oxygen from the placenta can be compromised or completely cut off. Every minute counts when the uterus ruptures. Even a 15 minute delay in performing an emergency C-section can result in the baby suffering permanent brain injury.
What Are The Risks Of VBAC?
While there is a 60-80% "success rate," for VBAC, this means that 20-40% of expectant mothers attempting a "trial of labor" will fail. While the overall absolute risk of death or injury from a "trial of labor" is not much different than with a C-section, there is a distinct increase in the risk to the baby, especially in the 20-40% of the cases where a "trial of labor" fails. If a rupture or tear does occur to the uterus, the risk of serious injury or death to the baby is greatly increased -- unless an immediate C-section is performed. Recent studies have determined that the risk of uterine rupture is three times greater for a "trial of labor" when compared to a planned repeat C-section. Moreover, the overall rate of delivery-related fetal death is eleven times greater for a trial of labor when compared to a planned repeat C-section.
Therefore, a potentially important question is: Are the risk to my baby's health higher or lower with a "trial of labor" than with a planned C-section? In simple terms, the increased risks associated with a C-section are all risks to the expectant mother's health, while the increased risks associated with a failed "trial of labor" are risks to the baby. These risks may be catastrophic if they occur. An expectant mother must carefully weigh and assess the risks to the baby when considering VBAC versus a repeat C-section.
What Must Be Explained Before Consent Is Given?
Whenever a woman is considering a "trial of labor," it is absolutely essential that she be fully informed of all risks to her and to her baby before she makes that decision.
For an expectant mother to give meaningful and informed consent she must be specifically told and understand that "IF HER UTERUS RUPTURES DURING HER VBAC, THERE MAY NOT BE SUFFICIENT TIME TO OPERATE AND TO PREVENT THE DEATH OF, OR PERMANENT BRAIN INJURY TO, HER BABY."
Only when that warning, and all other risks and benefits are explained, and understood, by the expectant mother can she give an informed consent to attempt a vaginal delivery following a previous C-section. Once such an informed consent is given, the medical care providers must carefully watch the mother throughout the labor process for any signs, symptoms or problems that might signal an increased risk of tearing or rupturing of the uterus.
Does The Mother Have The Right To End a Trial of Labor?
At any stage of the labor, the expectant mother has the absolute right to change her decision from a "trial of labor," to an immediate C-section. For the expectant mother to make an intelligent and informed decision, a continuous, open and honest dialogue between her and her medical care providers must exist. That is especially true for any events or changes during the labor that might increase the risk of continuing with the "trial of labor." Without this ongoing reassessment, the expectant mother cannot intelligently exercise her right to choose how her baby should be delivered.
How Do Hospitals And Insurance Companies Affect Your Choice?
As the cost of health care became an increasing concern over the past several years, managed care providers and insurance companies encouraged VBACs to reduce the cost of the health care they provided. Hospital charges were determined to be 1.7 to 2.4 times more expensive for a C-section than for the cost of a vaginal birth.
As part of their campaign to increase profitability by promoting VBACs, many health insurance companies and HMOs now authorize the same flat-rate payment to physicians for the delivery of a child, whether the delivery occurs by C-section or by vaginal birth. It is also common practice for hospitals to track the number of C-sections performed by individual obstetricians. If the obstetrician has a higher percentage of deliveries by C-section than that of other physicians, the doctor may be required to justify his or her decision to perform C-sections on various patients.
Contact Powers & Santola in upstate New York if your child suffered lasting birth injury or died as a result of fetal complications that arose during vaginal birth after caesarian section (VBAC). Our lawyers offer sound legal advice and honest answers in a free consultation
