March 15, 2010
Why Most VBACs Are Denied
A blue-ribbon panel of physicians, midwives and other healthcare providers convened at the National Institute of Health to discuss the dilemma of vaginal birth after cesarean (VBAC). At the end of the three-day-conference, they issued a statement that read: “Given the available evidence, TOL (trial of labor) is a reasonable option for many pregnant women with a prior low transverse uterine incision.” Most obstetricians know that, however convincing the hospitals is another matter.
The vacillation of VBAC policies makes me dizzy. In the late eighties and early nineties there was a tremendous effort to promote VBACs and dispel the myth of “once a cesarean section, always a cesarean section.” I recall the days of my residency training when we would call hospitals in foreign countries in an attempt to document a uterine incision of a pregnant patient who had one previous cesarean section and had presented to our hospital in labor. To section or not to section, was the issue at hand. If a woman had a vertical uterine incision, then she must have a repeat cesarean section to avoid the possibility of rupturing the uterus. However, is she had a low transverse or horizontal incision, than ideally, she was a VBAC candidate, barring any other issues such as more than two cesarean sections, fibroid surgery (aka myomectomy) and other uterine procedures that are too complicated to mention.
I blissfully remember taking care of a patient with two previous c. sections who presented in labor at 8 centimeters. She ultimately had a successful VBAC and I was greatly relieved. I dreaded doing repeat c. sections. Fighting layers of scar tissue (adhesions) from previous surgery is not a pretty sight when you’re attempting to reach the uterus and deliver a healthy baby.
Today, most hospitals will not allow VBACs unless the physician remains in the hospital during the patient’s entire course of labor. Since most physicians refuse to do so, a patient is forced to have a repeat c. section. When you deny a woman’s freedom of choice, please be prepared for the consequences. VBAC activism is on the rise and I hope it continues to spread.