Why won't my doctor let me VBAC?

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Top 5 fertility tests to do when you cannot get pregnantThere are many medical indications why a repeat c-section may be a safer option than a trial of labor after cesarean, such as a prior classical incision, prior uterine rupture or a history of three or more cesarean sections. However, there are also reasons why women may be told by their care providers that they are not “allowed” to attempt a VBAC even though they are a good candidate. Some obstetricians simply don’t offer them due to doubts about their safety or a prior bad outcome, but many other factors can also contribute to the decision by a hospital or care provider to not offer VBACs.

Recognizing a uterine rupture is a skill that takes quick thinking, experience and good clinical judgement. If a provider is not experienced in recognizing and managing complications associated with a trial of labor after cesarean section, then attempting one under their supervision is likely not the safest option. VBACs are generally very safe, but in the rare cases where things go wrong, the signs can sometimes go unnoticed unless you are being carefully monitored by a skilled provider. Additionally, many hospitals have a policy that the attending obstetrician needs to remain on Labor & Delivery for the entirety of a patient’s labor if they are attempting a VBAC. While this is usually feasible for doctors in large groups that rotate call with their partners, for an obstetrician in solo practice or in practice with a very small group of other doctors, this is often not possible. Be sure to ask your provider how often they take on patients attempting a VBAC and what your hospital’s regulations are on their oversight to gain a better idea of how experienced they are in safely monitoring them.

Many hospitals also impose VBAC bans because they are unable to provide the staff and resources necessary to quickly respond to a catastrophic uterine rupture. While uterine ruptures are rare, when they do occur, they need to be recognized and responded to immediately. At rural, small volume hospitals, the staff required to perform an emergency c-section, such as an anesthesiologist, is most likely not immediately available on the unit. It takes time to assemble an OR team, and the minutes that it takes to call in staff and prep for surgery could be the difference between life and death for mom and baby. Also, smaller hospitals rarely have NICUs that could provide lifesaving interventions for the baby in case of emergency. If you live in an area with multiple hospitals, you’ll be far more likely to find a provider willing to support a trial of labor after cesarean if they are affiliated with a larger medical center with more staff and resources.

Another factor that often contributes to a provider’s decision to offer VBAC is malpractice insurance. Many private practice obstetricians pay over $100,000 in malpractice insurance per year, and some insurers will not cover claims that result from bad outcomes after an attempted VBAC, leading providers to stop offering them. The fear of litigation has a tremendous effect on how some obstetricians practice. ACOG statistics indicated that in 2009, 26% of obstetricians stopped offering VBACs because of malpractice concerns. The litigious environment in which obstetrics is currently practiced plays a large role in what services providers and hospitals are able to offer based on the guidelines their insurance companies require them to follow.

Doctors and hospitals always have the best interest of mothers and babies in mind, and the decision to offer VBACs or not is made after carefully considering numerous factors. It is important to fully research your options and discuss VBAC early in your pregnancy with your care provider to understand all of your options. If you find that your OB or midwife is unable to offer VBAC, consider transferring to another practice who may be able to better safely accommodate your wishes.

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