In this article, Cliodhna Grady, Senior Clinical Risk Manager in the State Claims Agency, examines the litigation risks associated with Vaginal Birth After Caesarean Section, specifically in relation to counselling and consent, and how they can be mitigated.

Vaginal Birth After Caesarean Section (VBAC) describes a vaginal delivery in a woman who has given birth via caesarean section in a previous pregnancy. As caesarean section rates first began to rise in the early 1970s, it was generally felt that if a woman had a caesarean section, she should deliver all future babies by this route.

However, there is now a consensus that planned VBAC is a clinically safe choice for the majority of women with a single previous lower segment caesarean delivery.¹ Women who undergo successful VBAC avoid surgical recovery in the postpartum period. This approach also limits the maternal morbidity associated with successive deliveries by caesarean section. There is, however, a small risk of potentially serious complications, including a 0.5% risk of uterine scar rupture and a 0.08% risk of hypoxic ischaemic encephalopathy.²

Litigation risk

The State Claims Agency has managed a number of claims in relation to VBAC and a frequent feature of these claims is the failure to provide the mother with adequate information or counselling regarding the risks associated with VBAC, discuss alternative options or obtain informed consent. Lack of documentation in relation to consent and the discussion of risks is also a feature in claims.

Risk advice for practitioners

• Women who are being counselled for VBAC must be provided with comprehensive information about the benefits, risks and alternative approaches.
• There should be input from a senior obstetrician early in the pregnancy to allow for information to be shared in a timely manner and allow adequate time for discussion and consideration of the options available.

Patient information leaflets, checklists and consent forms

Research has shown that specific patient information literature and ‘VBAC checklists’ facilitate the decision-making process by lowering decisional conflict, improving level of knowledge, improving satisfaction and increasing women’s perception that they have made an informed choice.

Practitioners should adopt a comprehensive and consistent approach to the provision of information and the consent process and should consider:

• The use of a patient information leaflet to support antenatal counselling, which could be provided to the mother during the consultation.
• The use of a “VBAC versus elective repeat caesarean section” checklist and consent form to facilitate good practice in antenatal counselling and enable precise documentation of counselling and consent.

References available on request.