Vaginal Birth After Cesarean Section–Safe Or Not?

Back in the heyday of VBACs in the 1980s, vaginal birth after a cesarean section (“VBAC”) was common. However, as VBACs increased, so did the reports about complications, including uterine rupture, according to a recent article in Newsweek entitled “A Change of Delivery”.

In 1999, the American College of Obstetricians and Gynecologists issued guidelines stating that medical specialists be “immediately available” during a VBAC to treat a potential emergency–a standard that does not exist for routine labor. Many hospitals did not have the resources to comply and stopped offering VBACs. As a result, the rate of VBACs dropped from a high of 28 percent in 1996 to less than 10 percent today. Since 1996, one third of hospitals and half of physicians no longer allow women to have a VBAC.

The Newsweek article points out that a “trial of labor”, as its known among obstetricians, is safe in the majority of women and most babies and mothers do well. Women are more than capable to make well-informed decisions for themselves and their babies, including their right to have a VBAC.

There are several key points missing from the Newsweek article. First, while the risk of a uterine rupture is relatively small (ranging from 1% to 2%) for women undergoing a VBAC, the consequences of a uterine rupture for the mother and baby can be catastrophic, involve massive bleeding and can entail the rapid loss of life for the mother and baby. If the obstetrician and anesthesiologist are not available at the hospital when the mother’s uterus ruptures, the baby will be floating outside the uterus with no oxygen supply and fetal death follows in short order. When the uterus ruptures, the baby must be delivered immediately because any delay can result in the death of the mother and baby. This is why ACOG issued guildelines that an anesthesiologist and an obstetetrician be “immediately available” for VBACs.

If the ACOG guidelines for VBACs are relaxed and no longer require the “immediate availability” of the obstetrician and anesthesiologist, then the mother will be left with labor and delivery nurses with little training or experience in how to recognize the signs and symptoms of a uterine rupture. There are warning signs that often precede a uterine rupture that are caused by a partial tear of the uterine scar from the prior C-section, and a skilled obstetrician is much more likely to recognize the warning symptoms than a labor and delivery nurse. The warning signs of an impending uterine rupture can include shortness of breath, chest pain, agitation, neck and shoulder pain and severe pain between contractions.

As pointed out by the author of the Newsweek article, there are complications and risks associated with a C-Section just as there are for a VBAC. However, the potential risks and complications with a C-Section are not nearly as fatal and sudden as those associated with a VBAC. A uterine rupture is happen quickly and a physician should be immediately available to prevent the death of the mother and baby when it occurs.

The Newsweek article is one-sided in that it only points out the benefits of a VBAC while ignoring the potentially fatal consequences that can be associated with them. ACOG should not relax its guidelines that an obstetrician and anesthesiologist be “immediately available” for women undergoing a vaginal birth after a cesarean section and every patient should insist that its hospital follow the ACOG guidelines for a VBAC.