Can vaginal birth after caesarean be justified?



I read with interest the recent articles by Tahseen and Griffiths1 and Cahill et al.2 regarding the risks of vaginal birth after caesarean (VBAC). These authors appear to consider it reasonable to attempt VBAC even after two or three previous caesarean sections, despite the risks of uterine rupture, with its consequent severe maternal morbidity and serious perinatal outcome, recently highlighted in BJOG by Al-Zirqi et al.3 As a lawyer, I would question whether VBAC is ever reasonable.

I act for the pursuer [viz. the Scottish equivalent of claimant] in a major clinical negligence claim arising out of the delivery of her second child. My client had a caesarean section in her first pregnancy. When she became pregnant again, her consultant advised her to attempt VBAC. My client says that the risks of VBAC were not discussed with her, although the risks of elective repeat caesarean section (ERCS) were. During the course of her labour, the uterus ruptured. The baby suffered severe hypoxia, resulting in cerebral palsy. The defendant has admitted liability.

The risk of uterine rupture in VBAC is significantly higher than in ERCS, as emphasised in the ‘Green-Top Guideline’ number 45 of the Royal College of Obstetricians and Gynaecologists.4 If a rupture occurs, the consequences for mother and baby may be catastrophic.3 I find it difficult to understand why any mother would opt for VBAC if advised that the risks to her and her baby are significantly higher than with ERCS (not least as there is no reliable way of predicting imminent uterine rupture in an individual case so as to better manage the risk of adverse outcomes); moreover, I cannot see how a defendant or, in Scotland, a defender can avoid liability to a claimant who was not properly advised as to the balance of risks, and the consequences of the manifestation of risks, if she and/or her baby should suffer injury or worse during the course of VBAC.

Yet, it is my impression that the risks of caesarean section (including ERCS) are routinely stressed, whereas the risks of vaginal birth (including VBAC) are often downplayed, or even ignored. Not to give a balanced view of the risks is unjustifiable, both as a matter of professional practice and legal obligation. UK General Medical Council guidance has been clear since 1993: it is not for the doctor to promote one approach (here, VBAC versus ERCS) over another. The law reflects this professional duty: Chester v Afshar (2004) (House of Lords).

It is important to emphasise that failure properly to advise is not a matter of professional negligence, but a matter of the legal and professional duty to obtain informed consent. In my opinion, adherence to the Green-Top Guideline of the Royal College of Obstetricians and Gynaecologists is not enough to fulfil that duty. A doctor will be required to demonstrate that he or she has explained to the patient all material risks which, assessing the matter objectively, she would have wished to know about.

I am unable to understand the rational basis for running the risks of VBAC in preference to ERCS. Although it is accepted that the most recently available data are found in a paper of some age, the fact that a significant number of obstetricians elect to deliver a first child by caesarean section is telling.5 In my view, VBAC can only be professionally and legally justified when a full, unbiased disclosure of the risks of that procedure, as well as those of ERCS, has been made.