In December 2009, an Arizona woman made the news when, in her ninth month of pregnancy, she left her husband and three sons behind and traveled to Phoenix, six hours away from her home, to await the birth of her fourth child. She took these drastic measures because she wanted to give birth vaginally but her local hospital did not allow women who have had a cesarean section to attempt a vaginal delivery.
Last week, the NIH held a consensus development conference on vaginal birth after cesarean (”VBAC”) to evaluate, among other things, the sharp increase in elective repeat cesarean deliveries in the United States and the medical and non-medical factors that have caused it. The panel convened by the NIH found that both a trial of labor in women who have had a prior cesarean and an elective repeat cesarean delivery have “important risks and benefits” that “differ for the woman and her fetus.” A trial of labor is associated with a statistically significant increase in risk of uterine rupture and in risk of perinatal death. Elective repeat cesarean delivery, on the other hand, is associated with a statistically significant increase in risk of maternal death. Moreover, as the number of prior cesareans goes up, the risk of serious harm to both mother and baby does too, which is of particular concern to women who hope to have large families. As the panel notes, these facts and figures pose “a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa.”
The panel concluded that for certain women those with a “prior low transverse uterine incision” a trial of labor is a reasonable choice, albeit one that it increasingly constrained by difficulty accessing clinicians and facilities able and willing to offer it. Among the non-medical barriers to VBAC is a recommendation made by the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists that women with a prior cesarean not be permitted to attempt a vaginal delivery unless the hospital has “immediately available” surgical and anesthesia personnel. The panel concluded that this recommendation should be reassessed in light of “other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.”
The panel also found that “medico-legal considerations add to, as well as exacerbate” barriers to VBAC. Midwife Amy Romano, who writes the Science & Sensibility blog for Lamaze International, explains that because “lawsuits focus entirely on the counseling around [uterine] rupture rates, and doctors are sued if that counseling isn’t done or documented effectively, then the doctor has a financial incentive to focus on rupture likelihood[.]“ This steers women toward elective repeat cesarean delivery and exacerbates the already formidable liability barrier to VBAC. The panel predicted that “caps on noneconomic damages and reductions in physician malpractice premiums would result in fewer cesarean deliveries” and recommended that these and other interventions to reduce the liability barrier be developed, implanted, and evaluated to determine their efficacy.