Vaginal Birth After Cesarean -- What Are the Issues?

In This Issue: VBACs
Navigating Today's Healthcare Risks & Liabilities
August 2003
Vaginal Birth After Cesarean -- What Are the Issues?
Vol. 1, Issue 1
Janna Jones & Gwen Stokes, Consortium Management
Legal Briefs
For most of the prior century, the adage, "Once a cesarean, Always a cesarean" has
Multi- million dollar verdicts
been the rule of reason adhered to by most delivering physicians. During the late
& settlements are being award-
1970's many women began to verbalize a desire to experience a "natural birth" and
ed for liability cases resulting
risk a trial of labor. The successful results and the enthusiastic satisfaction these
from vaginal birth after
women proclaimed, led the
Cesarean.
National Institutes of
Health in 1981, to
Risk Management Calendar
promote trial of labor for
Upcoming meetings and work-
patients who had experi-
shops.
enced
previous cesarean
Patient Education &
delivery.
Informed Consent
In 1981, the US rate of
A discussion of needed docu-
successful vaginal birth
mentation and a case regarding
after cesarean (VBAC)
consent practices.
deliveries was only 3%,
with the overall cesarean
Resources
rate of 17.9%. By 1997, the incidence of VBAC rose steadily to 27.4%. Managed care
Here are additional resources
organizations (MCOs) recognized the potential savings that could be realized by the
to check on this topic.
shorter hospital stays and use of less costly resources with vaginal delivery. Many
MCOs therefore demanded a trial of labor in all cases where women met ACOG's cri-
teria to attempt VBAC. The cost savings was estimated at $2300 for a vaginal delivery
as compared to a repeat cesarean section. (1)
Managed care organization accountants had no way of predicting that by 1997, the
County of Los Angeles would pay $24 million to settle 49 claims for adverse out-
comes associated with VBAC.(2) These figures do not account for the millions more
expected to be paid for lifetime care of children who suffered profound brain injury
after labor complicated by uterine rupture. The policy requiring women to attempt a
Consortium Management
trial of labor was abandoned in 1995, in favor of allowing women to make an
is a subsidiary of McNeary
informed choice regarding VBAC.
and Attorney-in-fact of
As a result of the dramatic increase in uterine ruptures following previous cesarean
Consortium (A Reciprocal
delivery, ACOG revised criteria in 1999 restricting VBAC attempts to patients with
Risk Retention Group)
only 1 or 2 prior cesarean deliveries. In 2000, the ACOG Task Force on Evaluation of
Cesarean Delivery provided further recommendations to delivering physicians
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All Rights Reserved | For information, call Charlotte office 800-729-4149
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In This Issue: VBACs
Navigating Today's Healthcare Risks & Liabilities
Vaginal Birth After Cesarean page 2
and hospitals. The revised recommendations place more stringent requirements on hospitals and their delivering medical
staff.
Since ACOG is cited for establishing professional standards of care of delivering hospitals and physicians, it is important
that hospitals and their medical staff implement policies and procedures that meet ACOG's more stringent guidelines.
Hospitals should also be aware that as a result of ACOG's 1999 revised guidelines, the 2001 JCAHO Anesthesia Care
Standards were also revised to require hospitals that perform VBAC, to have anesthesia personnel immediately avail-
able to provide anesthesia for emergency cesarean delivery.
Who Are Candidates for a Trial of Labor?
According to the American College of Obstetrics and Gynecology (ACOG), appropriate candidates for VBAC exhibit the
following characteristics:
One or two prior low transverse incision c-sections
37 to 40 weeks gestation
Fetal vertex position
Otherwise healthy pregnancy
Clinically adequate pelvis
No additional uterine scars or previous rupture
Physician immediately available throughout active labor who is capable of monitoring labor and performing
an emergency c-section
Availability of anesthesia and personnel for emergency c-section
Contraindications to VBAC
Contraindications as recently published by ACOG include:
Prior classical, T-shaped or transfundal uterine surgery
Contracted pelvis
Medical or obstetrical complication that precludes vaginal delivery
Inability to perform emergency c-section due to unavailability of surgeon, anesthesia, other necessary nursing
personnel, or inadequate facility and/or equipment.
Other factors have been cited that may preclude a trial of labor following cesarean section. Such factors might include
multiple previous cesarean deliveries, unknown uterine scar, breech presentation, twin gestation, post-term pregnancy and
suspected macrosomia. Insufficient data exists to determine the efficacy and risks of VBAC among these groups.
Physicians should weigh the evidence of contraindications and continue to review studies to determine whether to rou-
tinely adopt VBAC under these circumstances.
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All Rights Reserved | For information, call Charlotte office 800-729-4149
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In This Issue: VBACs
Navigating Today's Healthcare Risks & Liabilities
Vaginal Birth After Cesarean page 3
Patient Education and Informed Consent
Physicians should ascertain documentation of any contraindications that they note during the prenatal assessment and also
confirm their findings of suitability for VBAC delivery. The patient should be fully informed of the indications and/or
contraindications for VBAC. Before deciding to pursue trial of labor, the physician and patient should ascertain that labor
and delivery will take place in a safe environment. A trial of labor should only be undertaken in a hospital setting where
anesthesia, surgical facilities, surgical personnel,
nursery facilities and personnel are immediately
available. Patients that desire a natural childbirth
experience should understand that continuous fetal
monitoring is a pre-requisite to attempting VBAC.
While the patient may desire the freedom to ambu-
late during labor, the physician should inform the
patient of the importance of continuous fetal moni-
toring during the trial of labor. Even a five or ten
minute delay in response can have a significant
impact on both the mother and baby if left unattend-
ed or treated.
Patient counseling regarding the risk and benefits of
a trial of labor should be documented in the patient's medical record. The physician should also document response to
patient's questions and concerns. If the patient views a patient teaching videotape or is given pamphlets or other educa-
tional literature, the physician should note this in the medical record also.
Following discussion of the risk and benefits of VBAC, the patient's informed consent for VBAC should be obtained. The
physician should provide the patient information about the associated risk, benefits and alternatives (including repeat
cesarean section). A uniformly constructed informed consent form should be provided to the patient. The signed consent
should be dated and witnessed by the physician. The informed consent should be forwarded to the hospital along with
copies of the prenatal records to the delivering hospital. At the time the patient arrives at the hospital in labor, a hospital
representative should verify with the patient their desire to pursue a trial of labor and proceed according to the patient's
current wishes. If the patient has additional questions or concerns or has changed their mind about a trial of labor, the
attending physician should be immediately notified and the patient's decision documented in the medical record.
Patients that verify their continued desire to attempt VBAC should again be reminded of the risk, benefits and alternatives
and their informed consent should be verified for accuracy and their continued desire to pursue a trial of labor.
Copyright ©2003 CONSORTIUM MANAGEMENT LLC & McNeary Insurance Consulting, Inc.
All Rights Reserved | For information, call Charlotte office 800-729-4149
6525 Morrison Blvd., Suite 200, Charlotte, NC 28211 www.consortium@mcneary.com

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In This Issue: VBACs
Navigating Today's Healthcare Risks & Liabilities
Vaginal Birth After Cesarean page 4
Labor Management
All laboring patients attempting VBAC should be monitored in the hospital setting. Physicians, anesthesia, and other per-
sonnel should be immediately available to perform an emergency cesarean delivery in the event of any complication.
Anesthesia and other OR personnel should be notified when a VBAC patient is admitted to labor and delivery. Obtaining
lab work, including a type and cross-match, upon admission to labor and delivery will save time in the event an emer-
gency c-section is necessary. The obstetrician should inform the laboring patient that continuous fetal monitoring will be
necessary during labor.
Oxytocin is not contraindicated for use during a trial of labor, but should be given judiciously. A study published in the
American Journal of Obstetrics and Gynecology found that neither uterine activity nor oxytocin caused uterine rupture.
However, because there is so much debate over the risk associated with using oxytocin during a trial of labor, a separate
informed consent should be obtained prior to oxytocin administration.
Epidural anesthesia was also once considered a contraindication to a trial of labor, but it has not been associated with
uterine rupture or a lower success rate of vaginal delivery. It is worth noting that the availability of epidural anesthesia
may actually encourage some women to choose a trial of labor over repeat cesarean delivery.
Facility, Personnel and Equipment
Careful consideration should be given as to whether a hospital is equipped and willing to meet the more stringent require-
ments for permitting vaginal birth after cesarean deliveries. While the incidence of uterine rupture is approximately 1%,
the rate of serious maternal and/or fetal morbidity or mortality is 10-25%. The ACOG recommendation for immediate
response for a maternal or fetal emergency has been interpreted by professional groups to mean that trial of labor or
VBAC should not be offered in level 1 or 2 maternity units that lack the necessary teams of obstetrician, pediatrician,
anesthesiologist, and support staff in the hospital at all times. Most authorities believe that even a 5 to 10 minute delay in
delivery can result in significant fetal harm.
If a hospital and medical staff determine that they can and will meet VBAC monitoring and delivery criteria, the expecta-
tions must be clearly communicated to all involved medical staff, nursing personnel, and other operating room staff.
Some hospitals opt to routinely "set up" an operating room in anticipation and preparation for an emergency delivery.
Immediate availability of emergency resuscitation equipment and personnel during a trial of labor and emergency cesare-
an section should also be verified upon the patient's admission to labor and delivery.
Of equal importance, is the availability and assignment of qualified nurses to monitor the patient's condition and progress
during labor. Fetal monitoring competency is critical to the successful management of the laboring VBAC mother. Labor
and delivery nurses should recognize the signs and symptoms of uterine rupture and know what immediate steps to take
should they become concerned about the patient's condition during labor.
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All Rights Reserved | For information, call Charlotte office 800-729-4149
6525 Morrison Blvd., Suite 200, Charlotte, NC 28211 www.consortium@mcneary.com

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In This Issue: VBACs
Navigating Today's Healthcare Risks & Liabilities
Vaginal Birth After Cesarean page 5
Risk Management Considerations
Thoroughly document all aspects of care, treatment, informed consent process, and labor management
Verify ability and availability of all necessary personnel, facility and equipment prior to agreement and pursuance of a
VBAC trial of labor.
Ascertain understanding and agreement of all respective parties as to expectations and responsibilities. (Obstetrician,
anesthesia, pediatrician, nursing, and operating room staff).
Inform patients that VBAC may not be permissible if their physician determines that a trial of labor is ill-advised or the
facility and/or personnel are unable to meet the "immediate availability" criteria.
Establish policies and procedures that detail expectations and responsibilities during VBAC trial of labor.
Physicians should not schedule other surgeries or appointments during VBAC trial of labor, to prevent delays in emer-
gency cesarean delivery.
Practice, practice, practice! Conduct emergency cesarean section drills periodically to review individual expectations
and readiness and availability of equipment and facility.
Is This Really A Problem?
Verdicts & Settlements
$98.5 million verdict - spastic quadriplegic infant as a result of ruptured uterus and delay in performing an emergency
cesarean section during VBAC attempt; defendant planned to appeal, but plaintiff settled for $4 million; California.
$24.16 million verdict - brain damaged infant due to failure to perform timely cesarean during VBAC attempt;
Pennsylvania
$18 million verdict - brain damage and cerebral palsy to infant due to delay in performance of c-section on mother
attempting VBAC whose uterus ruptured; California.
$14.85 million verdict - brain damage and cerebral palsy resulted from delay in performing cesarean when uterus rup-
tured during VBAC attempt; California.
$6.4 million settlement - brain damaged infant as a result of failure to perform timely c-section during VBAC attempt;
Texas
$3 million settlement - brain damaged infant due to uterine rupture and failure to perform timely c-section
during VBAC attempt; Texas.
$2.2 million settlement - brain damaged infant due to uterine rupture during attempted VBAC; Wyoming.
Copyright ©2003 CONSORTIUM MANAGEMENT LLC & McNeary Insurance Consulting, Inc.
All Rights Reserved | For information, call Charlotte office 800-729-4149
6525 Morrison Blvd., Suite 200, Charlotte, NC 28211 www.consortium@mcneary.com

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In This Issue: VBACs
Navigating Today's Healthcare Risks & Liabilities
Vaginal Birth After Cesarean page 6
A Lesson Learned About Informed Consent for VBAC
When physicians discuss the possibility of VBAC with their patients, they may opt to complete two consent forms: one
for the VBAC process and the other for cesarean section in the event of an emergency during labor. Will this measure
protect a physician and the hospital from allegations of failure to obtain informed consent?
The following case highlights some additional informed consent considerations.
Schreiber v. Figge , a Wisconsin Supreme Court case, raised the question as to whether a patient withdrew her consent for
VBAC during labor and whether it was then necessary for the physician to hold another informed consent discussion.
The case involves a patient who had two previous children delivered via cesarean section. The physician recommended
that the patient attempt a VBAC trial of labor, and the patient agreed. Upon admission to the hospital, the patient signed
consent forms for a VBAC and also for a cesarean section, should an emergency arise. After four hours of labor, the
patient informed her physician that she had changed her mind and now desired a repeat cesarean section. She subsequent-
ly complained of severe abdominal pain and reiterated her desire to have a cesarean section. Eight hours later, when the
fetal heart rate dropped, the physician proceeded with a cesarean delivery. It was discovered that the patient's uterus had
ruptured and the infant was deprived of oxygen in utero. As a result, the infant was born quadriplegic and was unable to
speak.
The patient sued the physician for negligence and lack of informed consent. The Wisconsin Supreme Court held that the
patient had withdrawn informed consent when she requested a cesarean section, thereby ending the permission she had
previously provided for a trial of labor and attempt of VBAC. The Court ruled it was then necessary for the physician to
hold a new informed consent discussion to advise the patient of all her treatment options. The Court found that the
patient's damages were a result of the physician's failure to conduct this second informed consent discussion.
What lessons can be learned from this case?
Patients have a right to withdraw consent to a trial of labor at any time prior to delivery
If consent is withdrawn, it may become necessary to obtain a second informed consent, which would include a discus-
sion of risks, benefits, and all options to the patient - including a continuation of the trial of labor and the option of a
repeat cesarean delivery.
The initial informed consent for both VBAC and cesarean section may be inadequate if the patient withdraws consent at
any time or if their condition significantly changes.
All parties need to be aware of situations and circumstances that may invalidate a previously obtained informed consent.
The physician should be informed if a patient voices concern or changes her mind about continuing a trial of labor.
Copyright ©2003 CONSORTIUM MANAGEMENT LLC & McNeary Insurance Consulting, Inc.
All Rights Reserved | For information, call Charlotte office 800-729-4149
6525 Morrison Blvd., Suite 200, Charlotte, NC 28211 www.consortium@mcneary.com

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In This Issue: VBACs
Navigating Today's Healthcare Risks & Liabilities
Vaginal Birth After Cesarean page 7
Conclusion
VBAC delivery is a viable option to repeat cesarean section under the right circumstances, in the right facility, and for the
right patient. Hospitals and physicians are advised to carefully consider the issues presented in this edition of The
Compass. For further questions or assistance in developing your hospital's policy and procedure, contact your Consortium
Risk Management Consultant at 1 (800) 729-4149.
Notice: The information contained in this issue of The Consortium Compass is not intended to be a substitute for specific
legal advice. The subjects discussed are intended to raise healthcare entities' awareness of quality improvement/risk man-
agement considerations.
Specific situations may warrant discussion with legal counsel as to the appropriate courses of action in specific situa-
tions. This publication may be copied for distribution within the recipient subscriber organization.
Calendar of Events - Risk Management
Additional Resources
ACOG Practice Bulletin, Number 5, July 1999.
September 17, 2003 Regional Risk Management
"Vaginal Birth after Previous Cesarean Delivery.
Education, "Patient Safety & Medical Error
ACOG News Release, December 12, 2001.
Reduction" Greensboro, N.C.
"ACOG Addresses Latest Controversies in
Obstetrics."
October 8 -10, 2003 NC ASHRM - Fall Meeting
Santa Barbara Health Authority - vaginal Birth
Greensboro, N.C.
after Cesarean Section, "Clinical Practice
Guideline.", August 1995.
November 2-5, 2003 ASHRM Annual Conference
National Institute of Health News Release, July 4,
Nashville, TN
2001. "Risk of Uterine Rupture During Labor Higher
for Women with a Prior Cesarean Delivery."
November 14, 2003 Risk Management Rounds
ECRI Risk Management Reporter, October 2002.
"Managing Patient Falls"
"In Review: VBAC: Study Shows Perinatal Death
Risk of VBAC."
Phelan, JR, M.D., "VBAC: Time to Reconsider?"
JCAHO Standards for Anesthesia Availability for
Parturients attempting VBAC; Section TX.2.1
Copyright ©2003 CONSORTIUM MANAGEMENT LLC & McNeary Insurance Consulting, Inc.
All Rights Reserved | For information, call Charlotte office 800-729-4149
6525 Morrison Blvd., Suite 200, Charlotte, NC 28211 www.consortium@mcneary.com

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