VBAC (Vaginal Birth After C-Section) Delivery and Birth Injury
Vaginal births after Cesarean section delivery (VBACs) increase the risk of serious health complications and emergencies such as uterine rupture (where previous C-Section scars tear and expel the baby and placenta into the abdomen). While uncommon, uterine rupture causes severe blood loss, birth injuries, hypoxic-ischemic encephalopathy (HIE) and cerebral palsy. Because of the severity of uterine rupture, emergency C-Sections must be performed within 2-15 minutes of the rupture. This occurs most commonly when labor induction drugs are used, when the mother is 35+, and when the mother has had multiple C-Sections prior to delivery.
What is a VBAC (Vaginal Birth After Cesarean)?
A VBAC (vaginal birth after C-section) delivery is the vaginal delivery of a baby by a woman who previously had a C-section. About 60-80% of low-risk women who have had prior C-sections can successfully deliver a baby vaginally with their future pregnancies. Despite this rate of success, however, there are still obstetrical situations in which VBACs are very dangerous and inadvisable. In recent years, VBACs have been attempted on fewer than 20% of women who have had prior C-sections. Due to the serious risk of uterine rupture with a VBAC, the American College of Obstetrics and Gynecology (ACOG) only recommends VBAC in very low-risk cases where patients are carefully chosen and given informed consent.
What is the Difference Between VBAC and TOLAC (Trial of Labor After Cesarean Section)?
TOLAC stands for trial of labor after C-section. It refers to a planned attempt to labor and deliver vaginally by a woman who has had a C-section in the past. TOLAC differs from a VBAC delivery in that a TOLAC has not yet resulted in a delivery; in other words, a TOLAC becomes a VBAC once the baby is birthed vaginally. So, a TOLAC has two possible outcomes: a completed VBAC, or a failed trial of labor that results in a repeat C-section delivery.
What Happens When Things Go Wrong During VBAC?
VBACs carry with them attendant risks. While many low-risk mothers may have a VBAC successfully, they should be provided with information that ensures they can provide informed consent about the risks of VBACs. Complications that can occur due to a VBAC include uterine rupture (which can result in massive bleeding and oxygen deprivation), infections, and the need for a C-section after a VBAC fails. In many cases, the baby may begin to show signs of fetal distress during a VBAC, and attempted VBACs can delay the amount of time between diagnosis and when the baby is delivered via emergency C-section.
Risks, Complications and Birth Injuries Associated with VBAC Delivery
Uterine Rupture and VBAC Delivery
The most serious risk associated with vaginal birth after C-section deliveries is uterine rupture. This occurs when the scar from the previous C-section tears open during labor and delivery. Uterine rupture typically results in expulsion of the baby and the placenta into the mother’s abdomen. When this occurs, there often is hemorrhaging (rapid, uncontrolled bleeding) that can cause the baby to be severely deprived of oxygen (hypoxia). This can lead to permanent brain damage from hypoxic-ischemic encephalopathy (HIE) resulting in developmental delays and cerebral palsy.
While the risk for uterine rupture appears low statistically (estimated between about 0.5% and 1.5% in low-risk vaginal birth after C-section deliveries), the outcome can be devastating. Uterine rupture can cause severe blood loss, hysterectomy, birth injury, hypoxic-ischemic encephalopathy (HIE), cerebral palsy or even infant death (about 1 in 20 of these ruptures results in fetal death).
When the uterus ruptures, medical professionals must act quickly. It is imperative that the hospital is equipped for immediate emergency C-section delivery and is able to deliver the baby within 10 to 15 minutes of the uterine rupture. This minimizes the chances of fetal oxygen deprivation and hypoxic-ischemic encephalopathy (HIE).
Research shows that uterine rupture is most common in three instances—when labor induction drugs such as Pitocin or Cytotec (prostaglandin) are used when the mother is over 35 years of age, and when the mother has had multiple C-sections. Medical professionals must consider these risk factors for VBAC and explain their dangers to the patient.
Infection and VBAC Delivery
In cases where a vaginal birth after C-section delivery is attempted but a C-section ultimately needs to be performed, there is an increased risk of infection in both the mother and the baby.
Failed VBAC and Emergency C-Section Delivery
Approximately 25% of vaginal birth after C-section delivery attempts fail in low-risk pregnancies and a C-section is required anyway. Medical professionals must discuss the potential for an emergency C-section with the mother and obtain informed consent.
Informed Consent Before VBAC Delivery
It is the responsibility of medical professionals to inform pregnant women considering VBAC/TOLAC deliveries of all the risks involved, as well as the alternative delivery option of a C-section. Medical professionals are obligated to explain the following details to patients in a way that they understand:
- The nature of the patient’s medical condition (VBAC)
- Who will perform the VBAC delivery
- The qualifications of the person performing the delivery
- The purpose of VBAC delivery
- The risks and possible consequences involved with VBAC deliveries
- Chances of the procedure’s success
- Alternative procedures to VBAC deliveries, as well as the risks involved with alternatives
- The expected recovery time
Discussing these considerations with a medical professional allows expectant mothers to make informed, educated decisions regarding their VBAC delivery plans and to understand the scenarios in which a C-section is necessary. If a patient has not been adequately informed and the mother or baby is injured during a VBAC or attempted VBAC, there may be grounds for a medical malpractice case.
Who Can Have a VBAC?
There are certain conditions that doctors must take into consideration when determining whether a woman is an appropriate candidate for a vaginal birth after C-section delivery. Typically, the best candidates have:
- A low transverse uterine scar but no more than two low transverse cesarean deliveries. Low transverse uterine scars are low, U-shaped scars.
- A previous vaginal delivery either before or after the prior C-section
- At least 18-24 months since the last C-section
- No additional uterine scars, complications or previous ruptures
- The medical reason for the original cesarean delivery is not present with the current pregnancy
- No other major medical problems with the mother exist such as diabetes, obesity, high blood pressure or genital herpes
- A single baby (a single gestation, as opposed to twins, triplets or other multiples)
- The baby is in the correct position (vertex presentation) and is not macrosomic (a larger than average baby)
- A patient who is not morbidly obese
As in any delivery, the baby should be monitored continuously and very carefully. If fetal distress signals are present and interventions (eg: amnioinfusion, oxygen, etc.) aren’t successful, then a C-section should be performed as quickly as possible.
Who Shouldn’t Have a VBAC?
There are certain conditions where women should not have a VBAC because the risks of complications occurring is too high. The only women who are considered candidates for VBACs are women who are not high-risk. This means that women who have a high-risk pregnancy should not attempt a VBAC.
VBACs are not recommended in women with risk factors including:
- Maternal obesity/overweight
- Genital herpes
- Blood clotting disorders
- If the mother has had less than 18-24 months since her previous pregnancy
- Prior uterine scarring, complications or prior rupture
- Twins, triplets or multiples
Additionally, women with a classical C-section scar or a T-shaped incision from their previous birth should not undergo a VBAC, because the risk of uterine rupture and severe bleeding is much higher in these women. Women with U-shaped scars may still potentially be eligible for a VBAC.
Note that a ‘low-risk’ classification at the beginning of pregnancy doesn’t make women necessarily good VBAC candidates. Things can happen during pregnancy, labor, and delivery that can require a C-section. These things include (but aren’t limited to):
- The baby is improperly positioned (sunny side up, feet-first, with a part that isn’t the head presenting first)
- The development of preeclampsia during pregnancy
- Macrosomic baby (a baby that is larger than expected)
- Intrauterine growth restriction (IUGR)
- Cord or placental complications (short cord, nuchal cord, true knot, vasa previa)
Will I Be Induced for a VBAC?
Induction for VBAC is not recommended. Medical induction of labor is always something that must be carefully monitored to prevent the risk of hyperstimulation (when uterine contractions come on too strong and too fast, keeping the placenta from replenishing the oxygen stores that go to the baby). Induction using Pitocin or Cytotec needs particular monitoring because the risk of uterine rupture with VBACs is higher. Pushing hard and fast contractions in the context of existing uterine scarring can significantly increase the risk of uterine rupture and massive hemorrhage.
Which is Safer: VBAC or C-Section?
VBACs and C-section each have their own attendant risks. Doctors who recommend one over the other balance the relative risks and benefits of each procedure.
How Soon Can Moms Have a VBAC After a C-Section?
In the context of VBACs, the risk of uterine rupture is least for women who have had a C-section longer than 18-24 months ago. The risk increases the shorter the time elapsed between pregnancies.
Medical Malpractice in VBAC Cases
Sometimes errors in judgment or practice by physicians and other medical staff can occur during a vaginal birth after C-section delivery. These can cause permanent and serious injury to the baby. Any medical mistake and deviation from care standards that results in injury to the mother or baby is considered medical malpractice.
Instances of medical malpractice in VBAC cases may include:
- Failure to inform the patient of risks involved with VBAC
- Allowing VBAC delivery for a patient who is a poor candidate
- Failure to abandon a VBAC attempt and properly and quickly perform a C-section when necessary
- Attempting a VBAC delivery in a hospital that is not equipped to handle emergency C-sections
- Failure to have in place and follow organizational policies and procedures for VBAC deliveries
- Failure to secure informed consent for an emergency C-section
- Failure to use fetal monitoring during VBAC
- Failure to respond adequately to changes in fetal monitoring
- Failure of the physician to give adequate informed consent
Legal Help for VBAC Injuries from Medical Malpractice
If you believe that your child has birth injuries as a result of negligence during a vaginal birth after C-section delivery or a failed VBAC attempt, we encourage you to contact Reiter & Walsh ABC Law Centers. Our Detroit, Michigan birth injury attorneys exclusively focus on birth injury cases, many of which include hypoxic-ischemic encephalopathy (HIE) and infant brain damage. Our compassionate, focused and knowledgeable approach to birth injury cases has earned us the reputation of being one of the best medical malpractice firms in the country. From our main location in Detroit, Michigan, our team handles birth injury and VBAC cases all over the United States. We’re able to help clients and their families in Michigan, Ohio, Arkansas, Mississippi, Wisconsin, Pennsylvania, Washington D.C., Tennessee, Texas, and other parts of the United States.
To begin your free case review, please contact our birth injury attorneys in any of the following ways:
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Video: VBAC Attorneys & HIE Lawyers discuss Birth Asphyxia & Birth Injuries
In this video, attorney Jesse Reiter discusses uterine rupture, VBAC, and HIE.