It used to be said that “once a caesarian, always a caesarian”, referring to the belief in the medical community that it was not safe for a woman who had had delivered a child by way of caesarian section to later attempt a trial of labor.  The adherence to this precautionary practice has, over the years however, been eroded.

During the 1980’s and 1990’s, many in the healthcare community, including managed care organizations, have adopted the policy or practice of attempting a trial of labor in women who have previously delivered by way of caesarian section, even in the face of unacceptable risks to the mother and the infant.  This practice has come to be known as a “VBAC” or “vaginal birth after caesarian.”

While the promotion of VBACs may save insurance companies money, the risks simply cannot and should not be ignored.  It is known that patients who fail a trial of labor are at increased risk for infection and death.  Infants born by repeat caesarian delivery after a failed trial of labor also have increased rates of infection.  Recent reports indicate that major maternal complications such as uterine rupture, hysterectomy, and operative injury were more prevalent in women who attempted a VBAC than those who underwent repeat caesarians. 

If the uterine scar ruptures, it can be life-threatening for both the mother and the infant.  For the mother, uterine rupture can require hysterectomy and can result in death. 

            For the infant, uterine rupture can result in both neurological damage and death.  Uterine rupture can result in a sudden disruption in the blood flow to the fetus, resulting in deprivation of oxygen to the blood and tissues.  This deprivation can lead to death of brain tissues and serious harm to other vital organs within only minutes.  Accordingly, it is imperative that no VBAC be attempted at a facility where emergency staff are not capable of performing an emergency caesarian in minutes in order to prevent this potential harm or death to the infant and mother. 

          Too often those in the healthcare community have promoted VBACs under circumstances which were foreseeably dangerous.  These circumstances included, but are not limited to

1.      Attempting a VBAC where there was an inability to immediately perform an emergency caesarean delivery because a surgeon, anesthesia, staff or facilities were not immediately available;

2.      Attempting a VBAC with a mother having a contracted pelvis;

3.      Attempting a VBAC when a medical or obstetrical complication precluded vaginal delivery;

4.      Attempting a VBAC following a classical or T-shaped incision or other transfundal uterine surgery.

It has further been found that the use of drugs for purposes of inducing labor can further significantly increase the risk of uterine rupture.  Particularly, the use of oxytocin (or pitocin) and prostaglandins can increase the relative risk of uterine rupture many-fold.  This added risk can arise if the physician desires for the labor to be completed during office hours and therefore seeks to induce labor using these drugs.

 In light of the very serious consequences which can arise in the context of attempting a VBAC, too often patients and their families are not adequately warned about the potential consequences of attempting a VBAC.

In too many instances, the doctor recommends early in the pregnancy attempting a trial of labor with little or no discussion of the serious risks.  Having a consent form flashed in front of the patient’s eyes for signature when the patient is admitted is simply insufficient to allow a patient to make an informed decision.