There has been much controversy in recent years over the use of VBAC (or vaginal birth after cesarean) as opposed to repeat cesarean sections (“C-section”) for mothers who have previously delivered via c-section. In the past, it was believed that a woman who delivered a baby by cesarean delivery would require a C-section for all future deliveries. We now know this is not always the case.
Each method of delivery carries its own risks and benefits and, unsurprisingly, the decision as to which method should be used often depends on highly individual factors. Doctors who adhere blindly to one method or the other thus risk injuring, or even killing, mothers and infants who are best suited to another choice. The failure to properly analyze each case and select the best option for the mother can thus constitute birth injury malpractice.
Cesarean sections, or c-sections, are surgical births. When a c-section is performed, a doctor cuts a hole into the mother’s abdomen, reaches inside, and manually delivers an infant. It does not take a medical expert to know that such a procedure carries risks. Among those are the risks associated with all surgeries, including possible infection, scar tissue, blood clots or pulmonary embolism, and anesthesia complications. C-sections also increase the risk that repeat c-sections or hysterectomy will be required.
Vaginal birth after cesarean, also called a trial of labor after cesarean delivery (TOLAC) is, just as it sounds, a natural childbirth following a delivery by c-section. Whatever choice is made can be dangerous if doctors and hospital staff are not properly trained and careful.
The benefits of a VBAC may include the following:
- Reduced risk of thromboembolism (blood clot in the leg or lung)
- Shorter length of hospital stay in most cases
- Less likely to need a blood transfusion
- Possible lower rate of postpartum fever, wound infection, uterine infection
- Fewer neonatal breathing problems
The primary reason that many women select VBAC is to avoid a second c-section, invasive abdominal surgery. The risks of injury at birth, both to the mother and infant, increase with each subsequent c-section, and with each year that the mother ages.
But attempts at VBAC are successful only 70-80% of the time. In the remaining 20-30% of VBAC attempts, a c-section is needed after the attempt, often on an emergency basis.
The greatest risk associated with VBAC is the risk of uterine rupture. Just as it sounds, a uterine rupture occurs when the uterus tears open during childbirth contractions, almost always at the site of the previous internal c-section scar. Because of the weakness of the c-section scar, uterine ruptures are more than twice as likely in VBAC births than ordinary vaginal births.
Still, less than 1% of VBAC attempts end in uterine rupture. But when ruptures do occur, the consequences are severe. One in twenty infants die in a delivery where uterine rupture occurs. The mothers themselves then have a higher risk of infection.
There are many factors, however, which influence the risk of uterine rupture in specific cases. For instance, if chemical induction of labor through pitocin is used (or labor is augmented in this fashion), the risk of uterine rupture increases by fifteen times. Indeed, our attorneys believe that the use of pitocin during a VBAC attempt is clear evidence of medical negligence at delivery.
Likewise, the type of incision used in the prior c-section greatly influences the risk of uterine rupture in an attempted VBAC. There are three c-section incision types: the classic incision, made high on the abdomen and vertically, the low vertical incision, and the low transverse incision (often called the “bikini” c-section). Either low incision carries a substantially lower risk of uterine rupture during VBAC.
There are numerous other factors which also influence VBAC risk, including the size of the mother’s pelvis, the reason or reasons for the prior c-section and the size and position of the baby. To avoid medical malpractice, a doctor must consider each of these factors before advising a patient on the decision between repeat c-section and VBAC.
So, why do many physicians and hospitals discourage or prohibit VBAC attempts, regardless of the individual factors? It appears that the culprit is physician convenience. Since 2004, the American College of Obstetricians and Gynecology (ACOG), the governing organization of virtually all U.S. obstetricians, has stated in its guidelines that when VBAC is attempted, the doctor and anesthesiologist must be immediately available – meaning present at the hospital throughout labor.
ACOG further states that VBAC is an acceptable option for women who:
- Do not have other conditions (as an example, placenta previa) that require cesarean delivery
- Have only one low transverse uterine incision from a past cesarean delivery
- Have no other uterine scars and has never experienced a uterine rupture
- Do not have pelvic problems or abnormalities that prevent vaginal delivery
- Have a baby in the proper position (head down)
Where such factors are not present, vaginal delivery should not be attempted; to do so may be considered medical malpractice. If you are pregnant after a previous c-section, be sure to speak to your physician about whether VBAC or repeat c-section is best in your particular case, and ask about the factors discussed above. Only once your individual situation is analyzed can you make the best, and safest, choice for you and your baby.
If you have any questions about a birth injury or medical malpractice matter, please give us a call us at 312-527-4500 or email us at email@example.com for a complimentary consultation. You can also learn more by following us on Twitter, reviewing our LinkedIn or Avvo.com pages, and by reviewing our website.