Saying No to VBAC: Why the Discrimination in U.S. Hospitals?

Hospitals who deny women the option to labor after a cesarean say they cannot provide an “immediate” emergency cesarean as recommended by the American College of Obstetricians and Gynecologists (ACOG) guidelines for VBAC  (Practice Bulletin #115) .

According to the National Institutes for Health, the risks of laboring for a VBAC are the same as for any other woman giving birth for the first time. Three out of four women who plan a VBAC give birth safely. The risk that the prior uterine scar may separate during labor (a serious medical emergency that requires a cesarean) is less than 1%. In fact the risk is lower than for any other unpredictable complication of labor that would also require an “immediate” cesarean. However, hospitals do not deny care for women who do not have a prior cesarean scar.  1_page_01

Here is what the National Institutes of Health said about laboring for a VBAC:

Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.

Women who have a trial of labor, regardless of ultimate mode of delivery, are at decreased risk of maternal mortality compared to elective repeat cesarean delivery.

žComparing mothers (pregnancy with all gestational ages) with a uterine scar who labored for a VBAC with mothers who had a scheduled repeat cesarean, the NIH review of pertinent studies found the following:

 

Maternal Mortality at Delivery Per 100,000 live births
Women who labored for a VBAC 3.8
Women who had a planned repeat cesarean 13

 

The chart below shows the odds of a uterine rupture in low-risk women laboring for a VBAC compared to other unpredictable complications that also require an emergency cesarean.

 

Per 1,000 women who labor Risk for complications
Uterine rupture (separation of uterine scar) 7-8
Shoulder Dystocia ( baby’s shoulders are too wide to fit through the pelvis) 6-14
Placental Abruption ( placenta separates from the uterus before the baby is born) 11-13
Umbilical Cord Prolapse (umbilical cord precedes the baby’s head through the cervix) 14-62

ACOG and the Society of Maternal-Fetal Medicine recently admitted in their Safe Prevention of the Primary Cesarean guidelines that too many cesareans are being performed exposing mothers and babies to avoidable harms without improved outcomes. Providing women medical care to labor for a VBAC can reduce their exposure to the harms of a cesarean section.

Denial of Informed Consent and Informed Refusal

Women have the right to an informed consent or informed refusal of either a routine repeat cesarean or a VBAC based on the information provided by their caregiver.  

Refusing to provide medical care for women who want to labor for a VBAC and forcing them to “consent” to a repeat surgery denies their right to bodily integrity, self-determination and the freedom to make their own healthcare decisions. It also puts mothers and babies at risk for serious complications that can have a life-long impact.

However, some hospitals have found a way to safely support women who want to labor after a cesarean despite the fact that they may not have the capability to provide an “immediate” cesarean when a woman is first admitted to the labor and delivery unit.

Parents can download slides of Module 9, If I Want a VBAC, Where Can I Give Birth?  and samples of VBAC-friendly hospital protocols and parent education forms from Deciding if a VBAC is Right for You for more information about having a VBAC in a hospital.