by Regula Elisabeth Burki, MD, FACOG
Partially under the pressure of lawsuits, the cesarean section rate increased from 5% in 1970 to 25% in 1988. Doctors are rarely sued for a poor outcome if they have performed a cesarean section but they are almost always sued when they have not. The courts firmly believed for many years that electronic fetal monitoring could identify practically every baby in trouble and that failure to recognize an abnormal tracing and immediately perform a cesarean section constituted "malpractice" and grounds for several million dollars in payment.
Doctors started practicing what is referred to as "defensive medicine" under the rule "when in doubt, section." Women paid with a high rate of often unnecessary cesarean sections. More recent research has shown that fetal monitor tracings are not as failsafe as previously thought and that many serious fetal problems start long before the onset of labor. The practice of "once a cesarean, always a cesarean," which dominated American obstetrics for nearly 70 years, further contributed to the high cesarean delivery rate, as did the fact that more older women with more medical problems and less stretchy tissues began having babies.
In the 1980s, it became clear that sometimes a trial of labor (meaning attempting labor) after a previous cesarean delivery can be safe for carefully selected patients. The National Institute of Health and the American College of Obstetricians and Gynecologists began to encourage the practice for carefully selected women with a low transverse uterine incision. Obviously, when a tiny woman with a small pelvis is expecting another ten-pound baby, the baby will not fit the second time around either!
Unfortunately, many managed care plans proceeded to mandate that all women must have a trial of labor before the insurance company would pay for a cesarean section, and went on a publicity campaign denouncing doctors and hospitals with high cesarean delivery rates. As a result, in many lay circles a doctor's cesarean rate became the sole criteria of competence as an obstetrician!
After 20 years of experience with VBACs, the following points have been shown by several well conducted studies: