Project Overview

VBAC refers to vaginal delivery after cesarean section. The rate of vaginal delivery after cesarean section peaked in 1996 and has been declining nationally since then.  Since 1999, Northern New England has seen a dramatic decline in the regional rate of VBAC. The decline began due to the lack of clear national standards, negative press coverage and excessive medical malpractice awards. By 2002, approximately half the hospitals in NH and several hospitals in VT stopped offering VBAC as an option for their pregnant patients. In response to the lack of choice for women residing in large areas of NNE, the obstetric departments at Dartmouth Hitchcock Medical Center and Fletcher Allen Health Care teamed together in 2002 to create the VT/NH VBAC project. The goal of the project was to increase the availability and patient and provider safety of VBAC in the region. The goal was accomplished through the collaborative creation of three documents listed below.  Since publication of the guidelines, all of the hospitals in VT resumed their VBAC services and more than ¾ of the hospitals in NH offer VBAC.

These VT/NH VBAC project documents were revised in January 2005 to reflect the 2004 ACOG Committee Opinion and published literature. They will have another round of revision in 2011.  The documents include:

1. VBAC Guidelines
2. Consent for Birth After Cesarean Section
3. Birth Choices After a Cesarean Section

These documents were created over a series of 5 open meetings and several telephone conferences. The first meeting was o­n April 22, 2002. The guidelines incorporate accepted national standards for the care of women with prior cesarean section. They include risk stratification for uterine rupture, and match resources to risk status. The guidelines present a local definition of "immediately available" as requested by the American College of Obstetricians and Gynecologists in their 2004 Committee Opinion on the care of women with prior cesarean section. The patient education materials clearly present the risks and benefits of a trail of labor after prior cesarean section and discuss the differences in resources of a tertiary level medical center and a community hospital. The education materials incorporate the principles of shared decision making. These documents were finalized o­n October 1, 2002 and revised in January of 2005.
The VT/NH VBAC project continued through the Northern New England Perinatal Quality Improvement Network (NNEPQIN), which was created in 2004.  NNEPQIN conducted a prospective study of regional QI data to describe the regional distribution of risk factors for uterine rupture, use of the regional documents, pregnancy outcomes in all women with prior cesarean sections, and resources used in trials of labor. 

A Brief History of VBAC

VBAC refers to vaginal birth after cesarean section. "Once a cesarean, always a cesarean" is perhaps an easily understood catch phrase, but it is a damaging phrase. Studies o­f the safety of VBAC, performed over the past 30 years, have consistently shown that VBAC is a safe option for women and carries a 0.5% risk of uterine rupture. In the 1980's and 1990's the VBAC rate steadily rose across the nation and in NH. However, in 2000 due to a variety of forces, the VBAC rate in NH started to plummet and about half the obstetric services stopped offering VBAC as an option. These forces include:

National Standards:  The lack of clear national standards for the care of women undergoing VBAC. The 1999 directive from the American College of obstetricians and Gynecologists stated that anesthesia and operating room services need to be immediately available, but that immediately available should be defined regionally. However, there is no mention of patient risks status. Most community hospitals lack the resources to create and test a local standard. If their local standard is substantially different from the "hospital down the road", they may be at increased liability should an adverse event occur, no matter how good the care is that they rendered. Regional standards, linked to patient risk and that account for the resources of the region are more practical.

Malpractice Premiums:  Excessive medical malpractice awards for families that have experienced a uterine rupture have threatened to bankrupt the medical malpractice insurers. This has caused many to raise their rates for physicians who are privately insured and also perform VBAC, to prohibitive rates that cannot be recovered through practice revenue. This effectively stops physicians from offering VBAC to their patient. Insurers have also pressured hospitals and administrators to close VBAC services, and have been very effective. There are few other procedures in medicine whose availability is dictated by malpractice insurers, and none that are so widely needed.

Publicity:  Since the publication of the landmark Lyndon-Rochelle article in 1999 there has been substantial negative publicity in the lay press and medical literature regarding VBAC. The negative publicity is in large part a back lash against health insurers that began mandating VBAC, and refusing to pay for repeat cesarean sections in the 1990s. However, Lyndon-Rochelle did not present new data about the overall risk of uterine rupture. They report a risk for uterine rupture with spontaneous o­nset of labor of 0.5%. The unique finding of their study was an unacceptably high rate of uterine rupture when prostaglandins were used to prepare the cervix for labor, around 2-3%.


VT/NH VBAC Project Mission

Our goal was to increase the availability and safety of VBAC for patients and providers across NH and VT.

Due to the lack of clear national standards, negative press coverage and excessive medical malpractice awards, the choice of VBAC has been taken away from many women and their physicians. In 2003, we polled providers in NH and VT, and found that 98% wanted to offer VBAC as an option to their patients. It is our strong belief that the decision to have a VBAC is very personal. Only a woman and her family, with input from her obstetric provider, can make this choice. Hospital administrators and medical malpractice carriers do not have a place in the decision process.


In addition, we feel that VBAC can be safely performed in community hospitals without excessive use of resources when patients are stratified by their risk. Low risk VBAC candidates are at the same risk for an untoward obstetric event as a woman undergoing her first labor. This does not require extensive modifications of routine care processes. Following JCAHO guidelines for the provision of obstetrical care is adequate. Medium risk patients can be easily identified and offered care at medical centers with 24 hour in house anesthesia and operating room personnel if desired by the patient and her provider. Few women will become high risk for uterine rupture during their labor. When this occurs, anesthesia and operating room personnel should become immediately available. Many women will have an indication for cesarean delivery at this point, and resources will be used effectively.


Actions of the VT/NH VBAC Project

DHMC and FAHC after noting the decline in VBAC services across VT and NH, and the resulting lack of choice for many woman, teamed together to create the VT/NH VBAC Project. The first meeting was April 22, 2002. Obstetric providers, nurse managers, hospital administrators, anesthesiologists and pediatric providers from all the hospitals in NH and VT that have birthing units were invited to attend. 35 of 37 hospitals were represented by 180 individuals. Invitations were sent to medical malpractice insurers, health care insurers, and public health departments, most of who attended. Work was begun on regional guidelines, patient education materials and consent forms. Five subsequent meetings with broad representation from across the two states were held, and these documents were finalized. The collaborative effort and interest in this project is remarkable, and points to the importance of allowing women to make decisions regarding their own care.

Since completing the documents they have been presented at regional meetings for ACOG and the ASA. A storyboard describing the project was presented at the Institute for Health Care Improvement in December 10, 2002. An analysis of the impact of closing VBAC services in VT and NH was presented at the 2003 ACOG National Meeting.  Since then, we have received hundreds of requests for the documents and have made them freely available on our website.   Finally, the availability of VBAC's, pregnancy outcomes in women with prior cesarean sections, and hospital resources utilized to labor VBAC's were tracked regionally using a simple data collection tool.  We hope to publish these results shortly. 

The Regional Impact of Lack of VBAC Options

Since 2000, the VBAC rate in NH fell from 36.74% to 20.12%, 8.00% due to lack of availability. In 2002, 372 extra cesarean deliveries, 179 due to lack of option, at a total cost of $1.4 million will be performed in NH. Although 14/33 hospitals no longer offer VBAC, 31/33 participated in the conference, and 97.2% of individuals polled wished to offer VBAC.

Approximately 12.5% of all pregnant women have had a prior cesarean delivery. Since 2000, the VBAC rate fell from 36.74$ to 20.12%, 8.00% due to lack of availability.  Cesarean section costs an excess of $3785 when compared to vaginal delivery (1999 data from the Health Care cost and utilization Project). In 2002, NH will spend over $700,000 extra dollars caring for women who had a repeat cesarean section rather than a VBAC.

If our goal were to prevent all cases of fetal injury due to uterine rupture, approximately 7.5 million dollars would be spent for each case of fetal injury from rupture that was prevented. This is based o­n a general risk of uterine rupture of 0.5%, a 10% incidence of significant fetal injury when rupture occurs, and the cost of cesarean delivery listed above. In addition to the economic costs, substantially more children would be require intensive care services due to respiratory complications at birth, some of them severe. The price of discontinuing VBAC services is thus substantial.