Vaginal Birth After C Section

In most communities in the US, vaginal birth after c-section (VBAC) is not offered. This has to do with malpractice liability and the risk of lawsuits against the doctors and the hospital.

When c-sections were first being done routinely there was a mantra “once a c-section, always a c-section”. As time went on people begin to try to have VBACs and it was found to be safer than thought. Part of the reason was that the way the uterus was entered changed and most surgeons were doing low transverse incisions rather then vertical incisions into the uterus. These incisions tend to heal stronger with less risk of rupture. Eventually, more and more women were having VBACs and the risks were better understood. VBACs became the standard and were usually recommended for women with just one c-section. The American College of Obstetrics and Gynecology (ACOG) came out with a statement that said in order to do a VBAC safely, an obstetrician, anesthesiologist, operating room, and operating team had to be immediately available. The word “immediately” became a point of difficulty in malpractice claims and hospitals began deciding not to offer VBAC.

The situation we have now is that in most communities in the US, hospitals do not offer VBAC. In my community, for example, women need to deliver in a hospital in a different county if they want to VBAC. This becomes very impractical for most women, so the option to have a VBAC does not practically exist.

The risk of VBAC is that the scar will rupture during labor. The risk is low and thought to be around 1% in a good VBAC candidate. If the uterus ruptures, a c-section needs to be accomplished very quickly to save the life of the baby and sometimes the mother as well. It is estimated that in 50% of uterine ruptures there is significant damage to the baby. This risk goes up greatly in a situation where a c-section would be delayed such as in a birthing center or at home. So if the hospital does not allow VBAC, delivering at a birth center carries significant risk, and I would not recommend it.

The hospitals that allow VBACs in the US tend to be large teaching hospitals. They have more redundancy in the staffing of both doctors and nurses and also tend to be self insured. Our hospital, for instance, will not allow VBACs because the hospital’s malpractice insurer does not cover VBAC.

In my opinion, this is a very unfortunate situation. This is a classic example of the legal environment forcing medical decisions. I am hopeful that this will change in the future, and we will again have the freedom to offer VBACs to our patients. It will probably require significant malpractice liability reform for those changes to become reality.