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VBAC Cubby - vaginal birth after cesarean

Current VBAC Climate
by Cynthia Flynn, CNM, Ph.D.
Cynthia FlynnQ. I have been reading/hearing in the news that doctors are moving away from doing VBAC. I had my first child in April 2002 via c-section due to his head getting stuck in the birth canal. After 4 hours of pushing, the midwife called in the OB who decided a c-section was necessary.

I would really like to have my next child vaginally. I am trying to get as educated as possible now. What is the overall mood currently about VBAC? Is what I am hearing true? Any light you maybe able to share on this subject is appreciated.

A. In the 70's, the only place you could get a VBAC was at home--"once a cesarean always a cesarean" was the rule for hospitals. But it became clear that when the surgeons changed from a vertical incision to a "bikini cut" that was transverse, the risk of uterine rupture was much lower. Gradually, hospitals developed protocols that allowed VBAC, and the women came back into the hospital to deliver.

Then the health insurance companies got into the act, and by the late 80's, they were pressuring providers to practically insist on a trial of labor before repeating the cesarean. Studies showed the benefit to the baby of going through some labor even if there was a repeat cesarean. And of course there were the financial considerations, as cesarean expenses were at least triple those of a vaginal birth. Insurance companies were providing feedback to providers about their cesarean rates compared to their colleagues, and hospitals were doing the same. The national cesarean rate dropped from 30+% of deliveries to the low 20's. "Good" OBs had cesarean rates of about 15% of their deliveries.

Recently, the medical malpractice insurance companies have gotten into the act. Face it, there is no country on the planet that sues more than we do. If anything goes wrong, it must be someone's fault (other than ours) and they should pay. There is no question that with every VBAC, there is a risk, however small, that the uterus will rupture and the results may be catastrophic for mother and/or baby. These cases invariably result in a suit. No one ever sues for an unnecessary cesarean (though I see women who almost certainly have had them all the time). But they sue if there is a problem with a VBAC, even though they have signed informed consents that detail the possibilities.

So even though the risk of a problem with a VBAC might be low, the settlements are very high in cases where a problem develops. With more and more VBACs, even though the rate of problems was not high, the absolute number of malpractice suits associated with VBACs increased. The malpractice insurers began pressuring hospitals and providers to find ways to reduce the risk. Bulletins from the American College of Obstetricians and Gynecologists (ACOG) over time reflect this increasing pressure.

Things came to a head in Spring 2002. At that time, the guidelines stated that if there was a need for a "crash" cesarean, the baby had to be delivered within 30 minutes. The woman in question had been properly consented for a VBAC, her uterus ruptured, the baby died, and she sued. The physician felt he had done nothing wrong according to the standard of care, as the baby was delivered in 27 minutes and the woman had known the possible risks and agreed to assume them. Therefore, the physician was unwilling to settle the suit out of court and went to trial.

Despite all this, the jury found for the woman, and awarded her $98 million. The judge upheld the verdict. Want to guess how long it would take me and all my friends to pay *$98 million* in malpractice insurance? ACOG promptly changed its guidelines to read that in the case of VBAC, the cesarean had to be performed "immediately" which has been interpreted to mean within five minutes.

This means that many hospitals without 24-hour anesthesia cannot do VBACs unless the woman has an epidural, so that the anesthesiologist has to stay in-house (and will be paid to do so). Hospitals that do not have an OB in-house 24/7 are requiring that the OB stay in the hospital while the VBAC labors and they can't be doing other surgery. Smaller rural hospitals have stopped doing VBACs altogether. At our hospital, they have made a slight exception for OBs whose offices are next to the hospital, and said they can be in their office while the woman labors. But at night/weekends, the OB has to come in and stay at the hospital. So in our town, if you can get a VBAC at all, you are likely to be induced during office hours and be required to have an epidural. Good luck with the VBAC in that case! In this state, midwives who were doing VBACs at home (it was never allowed in birth centers by state law) lost their malpractice insurance for home VBACs.

So now, as a midwife, I am in the weird position of not being able to care for women who desire a VBAC (the OB doesn't want to sit at the hospital while I collect the fee for delivery--rightly so), but I can care for women who desire a repeat cesarean, at which I will assist. Go figger!

I foresee that this situation will not change until the consumers have a major fit about it. I have clients whose first birth was a cesarean and who have had VBACs with me ever since who are very upset. I can be their (unpaid) doula, but that's it for now. In my view, it's the public (in the form of clients, juries and judges) that have created this problem and the public that will have to solve it. Until we are willing to take responsibility for our decisions--no matter the outcome--and get over the idea that we are entitled to a perfect outcome or somebody must pay, what you see is what you get. Until the family and friends and pastors and lawyers of the woman who has lost a baby during a VBAC tell her not to sue, or the juries refuse to award her money for a decision she made ahead of time, we are stuck with the current situation.

Since you asked. This is only my personal view of recent history, but I hope it helps you to put into context what your midwife might tell you. Good luck with your own VBAC.

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