VBAC risk results in strict criteria or total ban

Vaginal birth after cesarean (VBAC) was tied to a number of obstetrics claims in the Hospital Corp. of America (HCA) system, and inexperience in this procedure may have contributed to the problem, notes Janey Myers, RN, assistant vice president of the HCA perinatal safety initiative.

The HCA system includes several smaller hospitals, and some were performing VBAC before they were ready, she says. VBAC is somewhat controversial because it can be dangerous for some patients, but even those professionals who advocate its use say it must be done carefully and with staff who are prepared to respond if anything goes wrong, Myers explains.

Unfortunately, the data collected by HCA suggested that some of its hospitals were performing VBACs without the proper staffing or safety measures, Myers says. That may have been attributable to a push in recent years among some patients who seek a VBAC rather than going through a second cesarean.

"Most hospitals, including many of ours, do not have 24-hour obstetrics coverage with doctors there ready to respond at any time," she says. "The literature on VBAC clearly shows an increased rate of uterine rupture, and the professional groups have gone from saying that a physician should be 'readily available,' to saying they should be 'immediately available,' but still without defining what that really means."

HCA leaders decided that they needed to define the term and hold member hospitals to certain criteria. For HCA hospitals, "immediately available" now means the physician must be at the bedside within five minutes. That is a tough standard for some hospitals to meet because it requires substantial cooperation from on-call physicians. In addition, hospitals had to guarantee compliance with minimal staffing and competency guidelines and provide additional education regarding VBAC.

"So some of our hospitals had to determine whether they were going to continue offering VBAC, whether it was going to be feasible in terms of their staffing," Myers says. "If not, they were going to just have to say that VBAC is too risky for them and they can't do them anymore."

The issue was not debatable for HCA hospitals. They either had to meet the new criteria or stop doing VBAC, and many decided to just stop. The rate of VBAC among all deliveries in the HCA system was 15.3% in 2001 and fell steadily to 7.5% in 2004.