RH Reality Check is reporting that Jennifer Goodall, a woman in her late 3rd trimester with 3 previous c-sections who wants to attempt a vaginal birth has been notified by the chief financial officer of the hospital where she planned to deliver (Bayfront Health Port Charlotte) that her “prenatal care providers intended to report her to the Department of Children and Family Services, seek a court order to perform surgery, and perform cesarean surgery on her “with or without [her] consent” if she came to the hospital.”
I don’t have many more facts other than Ms. Goodall had 3 c-sections and now wants to consider a vaginal birth after c-section (VBAC), but I really don’t need any because no competent adult should be forced to have any medical procedure. Ever. And the implied threat of reporting someone to the Department of Children and Family Services counts as force.
What are the medical risks of attempting a VBAC after 3 c-sections? I have done a few in highly motivated low-risk patients. There aren’t a lot of prospective studies, but a retrospective review of over 25,000 women with at least 1 previous c-section indicates that the chance of a successful VBAC after 3 previous c-sections is about the same as after 1 and the risk of complications for mother and baby are about the same in both groups. In fact, 79% of women with 3 previous c-sections had a successful VBAC.
There is infinitely more data for a trial of labor after 1 or 2 previous c-sections, summarized here in this document from the American Congress of Obstetrician and Gynecologists. The risk of uterine rupture is higher after 2 c-sections (uterine rupture is the big complication). In the study I just quoted there were no uterine ruptures, however only 89 women had a VBAC and so there were just not enough women to know. Another study also reported a 79% success rate (Miller et al) also retrospective, so not the highest quality of evidence). The Miller study had over 200 women and reported a 1.2% risk of uterine rupture (on par with the 2 previous c-section data).
There is not a lot of good data on labor after 3 previous c-sections because the number of women who do so is quite small. However, the literature, such as it is, does not at all indicate that a low-risk woman with 3 previous c-sections is endangering herself or her fetus if she enters labor spontaneously in a facility equipped for an emergency c-section. Repeat c-sections, as you can see from the chart, are not without risks and so the desire to VBAC is not some kind of fool’s errand or crunchy-granola-new-age-mumbo-jumbo.
The ACOG opinion on more than one previous c-section is as follows:
…the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC. Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited.
(TOLAC= trial of labor after c-section)
Are there situations where attempting a VBAC is contraindicated? Yes, some examples might be a vertical scar in the uterus (up and down, this is weaker and is more likely to rupture), if it looks like the placenta is invading the c-section scar (placenta accreta), or if the placenta is covering the cervix (placenta previa). However, even with placenta previa or accreta, situations where a catastrophic outcome is almost certainly guaranteed without a c-section a woman still has the right to turn down medical care.
This is not the first time a hospital and court in Florida have attempted to force a woman to have a c-section against her will and a woman also reports she was forced to have a c-section against her will at Staten Island University Hospital. What I don’t understand is if these threatened/forced c-sections are born from the OB/GYN and/or hospital’s fear of lawsuits (a significant percentage of OB/GYNs don’t offer VBACs because of fear of lawsuits), the insurance carrier refusing to cover VBACs (either the doctor and/or the hospital’s carrier), a complete lack of knowledge of the literature on VBACs, or some highly misguided pro-fetus-anti-woman agenda. Remember, a repeat c-section (especially a 4th one, or what we call a four-peat) is not without maternal risks.
The “best case scenario” I can come up with (I use that term lightly) is that the hospital’s insurance carrier (or the perinatal group’s) won’t cover a VBAC after 3 previous c-sections and so they are trying to scare her away. Alternative scenarios involving life of mother over life of fetus are even more frightening; if the courts consider that a valid argument then really the sky’s the limit because it means a pregnant woman would essentially give up her rights for 9 months in deference to her uterus.
Someone needs to figure out the motivation behind these cases. If it’s pure medicolegal then serious tort reform is needed around VBACs. If there’s more to this, well, there is a lot more work to do because the implications are terrifying.