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Limiting Your Liability: Planning a Safe VBAC |
A study published in the July 5, 2001 edition of the the New England Journal of Medicine suggests that widespread adoption of VBAC (Vaginal Birth after Cesarean) may be putting both mother and child at unnecessary risk of uterine rupture when labor is induced.
In examining 20,000 birth records for the study, researchers found that only 1-2% of women attempting VBAC suffered uterine rupture, but that risk increased fifteen times when labor was induced with prostaglandins. While that number is still comparatively small, uterine rupture requires that the physician perform an emergency C-section immediately, before the child suffers severe brain damage or death. The mother's life may be endangered as well, due to massive blood loss, infection, or other postpartum complications.
While the American College of Obstetricians and Gynecologists recommends the option of VBAC for women with one previous surgical delivery and a low-transverse incision, physicians still face enormous liability exposure with VBAC - especially when a high-risk mother decides to attempt a trial of labor, or when inadequate medical facilities make a timely emergency C-section difficult or impossible. As the following case study demonstrates, however, physicians can significantly reduce the malpractice risk they face when their patients consider attempting VBAC:
A patient whose second child was delivered by C-section was admitted into a hospital when she went into labor with her third child. (Her second delivery was via C-section due to her failure to progress during labor.) The patient stated she wanted to attempt a trial of labor, with the hope of minimizing post partum recovery time. Upon arrival at the hospital, however, the patient complained of abdominal pain that was most severe when she was most lying flat, and less severe when she lay on her side. Pitocin was administered, and contractions were noted in the medical record. Early in the afternoon, the patient's OB/GYN left to conduct office hours at his clinic, and the patient was left in the care of another physician. Two hours later, Pitocin was re-administered, and the attending physician was called in when the fetal monitor strip showed a loss of baseline heart rate, as did a fetal scalp electrode. The attending physician ordered an emergency C-section, yet the operation was delayed for approximately eighty minutes. In the meantime, the patient's OB/GYN was called in and joined the C-section after it was already in progress. When the patient's abdomen was opened, free blood was noted underneath the peritoneum. The fetus was delivered with no evidence of movement, heart rate, or breathing. After resuscitation, intubation, and subsequent transfer to another hospital, the child experienced repeated seizures and remained mentally unresponsive. A few weeks later, the child was extubated and died soon afterwards. An autopsy revealed death secondary to intrauterine anoxia, secondary to uterine rupture. The child's mother sued for malpractice, alleging that 1) she had never been informed of complications with VBAC, and 2) the delay in surgery killed her newborn due to uterine rupture. |
Risk Analysis
Failure to consider contraindications to VBAC
Physicians must discuss the potential risks of VBAC with patients considering trial of labor, based on an assessment of the mother's delivery history. If a previous C-section was the result of failure to progress in labor, or if a patient has more than one uterine scar, the patient should be considered a high-risk candidate for VBAC. Patients who are at higher risk for uterine rupture can still attempt a trial of labor, however, as long as they remain under continual observation in a facility that is adequately staffed and equipped to handle an emergency C-section in a timely fashion.
Use of Pitocin
As indicated in the NEJM study, induction of labor increases the risk of
uterine rupture with women attempting VBAC. Oxytocin (Pitocin in this case) increases the risk of uterine rupture when administered to mothers attempting VBAC, although not to the same degree as prostaglandins. This risk factor was apparently ignored or unknown by those who were caring for the patient during her delivery.
Failure to adequately monitor the patient and respond appropriately
The source of the patient's abdominal pain was never evaluated; data from the fetal heart monitor and fetal scalp electrode were not monitored closely; an intrauterine pressure catheter (IUPC) was not utilized; and the attending physician left the hospital to conduct office hours. After the covering physician belatedly performed the C-section, the patient's mother complained that she had noticed changes on the fetal heart monitor before the physician and nursing staff did.
Failure to adequately document care
The physician and hospital medical records contain no written documentation regarding a discussion of VBAC risk factors, prior to the patient's trial of labor. Also, there is no mention of what course of action would be taken should the VBAC attempt fail.
Risk Reduction Recommendations
Establish clinical eligibility for a VBAC
While candidates for VBAC must be considered on a patient-by-patient basis, the American College of Obstetricians and Gynecologists recommends the option of VBAC for women with one or two previous low-transverse cesarean deliveries, with no other uterine scars or previous ruptures (see inset for details.)
Frequently, the hospital where the patient will attempt a trial of labor needs to be factored into the eligibility process as well. In order to minimize risk to both patient and child, VBAC should only be attempted at hospitals with surgeons and anesthesia available 24 hours a day, along with adequate support staff and equipment to perform an emergency C-section in less than 20 minutes after warning signs that uterine rupture has occurred.
If the patient does not have access to a hospital adequately equipped and staffed to handle an emergency C-section in the time frame necessary, she should be referred to a board-certified physician with admitting privileges in a hospital that can safely accommodate emergency surgery. All patient referrals should be documented in the medical record.
Exercise caution in use of oxytocin, prostaglandins, and epidural analgesia during trial of labor
NEJM data indicates that oxytocin increases the risk of uterine rupture, while prostaglandins should be avoided altogether. While it is unclear why prostaglandins cause far more risk than oxytocin, research suggests that oxytocin dosages (administered invtravenously) are easier to regulate than prostaglandins (administered topically.) The main risk of epidural analgesia, on the other hand, is that it can mask the sharp, "tearing" abdominal pain that indicates uterine rupture.
Perform an emergency C-section at the first sign of sudden onset of severe variable decelerations or prolonged bradycardia
While properly monitored fetal heart monitors and fetal scalp electrodes will indicate dangerous drops in fetal heart rate, an intrauterine pressure catheter (IUPC) should be considered for patients with more than one uterine scar. The IUPC will give a vigilant physician an "early warning" about loss of pressure in the uterus, indicating uterine rupture. All of these devices should give ample warning that the trial of labor should be terminated, and an emergency C-section performed as soon as possible.
Aside from fetal heart monitors and IUPC readings, however, a sudden onset of sharp, continuous abdominal pain felt by the patient is another clear "early warning" of uterine rupture. If epidural analgesia is applied during the trial of labor, however, the physician loses this warning mechanism because the patient may not feel any abdominal pain.
Thoroughly document all aspects of care
The patient medical record must indicate that the patient received adequate consultation and information from her physician regarding the benefits and risks of VBAC. The record must also indicate that the patient understands that the trial of labor should be attempted in a hospital with on-call emergency surgical staff capable of performing an emergency C-section within twenty minutes of detection of uterine rupture. An informed consent form, signed by the patient and placed in the patient file, is recommended.
ACOG Guidelines for Identifying VBAC Candidates
- One or two previous low-tansverse cesarean deliveries
- Clinically adequate pelvis
- No other uterine scars or previous rupture
- Physician immediately available throughout active labor capable of performing an emergency C-section
- Availability of anesthesia and personnel for emergency cesarean delivery.