A 30 year old married woman was pregnant with her second child. Her first child was delivered by emergency Cesarean Section, commonly referred to as c-section. Her medical insurance was provided through her husband's employer. She became pregnant for the second time soon after her insurance coverage began. Her prenatal care and delivery were at the same facility.
She presented to the hospital for delivery at 38 1/2 weeks. Even though she had had a prior c-section, the plan at this hospital was to try to deliver vaginally and not deliver by repeat c-section. This option is known as a VBAC or vaginal birth after c-section. Since there had been a prior incision in her uterus for her first delivery by c-section, a VBAC for the second pregnancy had an increased risk of a ruptured uterus as a result of laboring for many hours. A repeat c-section instead had no such risk of rupture, but did have the ordinary risks of surgery.
Rupture of the uterus can be a life-threatening event for both the mother and baby. In term pregnancy, the uterine blood vessels and placenta are engorged with mother's blood which is the life support for the baby. A rupture diverts that blood away from the baby and deprives it of oxygen. The outcome can be fetal death or devastating brain damage and lifelong severe disability. Very careful monitoring during labor by highly skilled medical and nursing staff, as well as prompt delivery by repeat c-section at the first sign of fetal or maternal distress is crucial.
In this case, the mother presented to the hospital in early labor at about 6:00 am; she was monitored for 2 hours and sent home. Later that same day at about 6:00 pm she returned with more frequent contractions. She was admitted to the labor unit and monitored. She was not delivered for 17 hours. Delivery was done by emergency c-section for fetal distress caused by a ruptured uterus.
During the 17 hour labor at the hospital, she was making very slow progress toward a safe vaginal delivery. Her cervix was not opening as quickly nor was the fetus moving down the birth canal as would both be expected for a safe vaginal delivery.
More importantly, during this long labor, the fetus was showing signs of inadequate oxygen to its brain. The nurses did not recognize the signs of fetal distress as shown by decelerations of the fetal heart rate that worsened as time progressed. Instead the nurses had her continue to push toward a vaginal delivery. Pitocin, the drug to augment the frequency and strength of contractions, was continuously administered to the mother despite the evidence that the fetus was not and could not continue to tolerate this "trial" of labor with its intense contractions.
Ultimately an emergency c-section was done and a very damaged newborn was delivered. The uterus was ruptured and the newborn infant asphyxiated. Studies done on the baby's brain afterward, showed classic evidence of brain damage caused by asphyxia (too little oxygen and blood during labor).
The child is now almost 3 years old, does not walk or talk, has a seizure disorder and needs 24 hour care for the rest of its life.
It is important to note that medical facilities and staff often "push" women to opt for a trial of labor and attempted VBAC. If successful, it requires a shorter hospital stay, no use of an operating room or the services of assistant surgeons and anesthesiologists. It is cheaper for facilities that don't bill for service but simply have, essentially, a membership fee.
VBAC may be appropriate, with proper informed consent, but only if very careful monitoring is done by well-trained staff who are not otherwise "too busy". Knowing when caution is the better part of valor is the key.
Fill out the form below to find out if you have a case