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Birth Injuries - ICSI Guidelines for Vaginal Birth After Cesarean

Posted by attorney James Girards

Sometimes severe injury or death can result when a vaginal delivery is attempted after a previous child was delivered by cesarean section. Frequently, neither of the parents were told of the risks involved and in many of these deliveries the hospital failed to have the required resources available to assure a safe delivery if the foreseeable complications arise. What follows is an excerpt from the ICSI Guidelines on VBAC (Institute for Clinical Systems Improvement (ICSI). Management of labor. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2009 May). It is provided here for the reader's information related to this issue.


  1. Special Considerations of Labor Management
    • Availability of team capable of performing a Cesarean delivery within a short time [R]
    • Review the prior operative report(s) to ensure that the uterine incision did not involve the contractile portion of the uterus such as a classical incision. A VBAC after a Caesarean with classical incision carries a tenfold higher risk of uterine rupture compared to a low transverse uterine incision.
    • Intermittent auscultation or continuous electronic fetal heart rate monitoring should be done. See Intrapartum Fetal Heart Rate Management algorithm and annotations.
    • Augmentation or induction of labor with oxytocin increases the risk of uterine rupture [C] though the risk is still low (1% to 2.4%). Oxytocin and prostaglandin were not individually associated with uterine rupture except when sequential prostaglandin-oxytocin was used [R]. A meta-analysis [R] found sufficient evidence to help in choosing planned induction in VBAC versus elective repeat Caesarean delivery.
    • The ACOG Committee on Obstetric Practice recommends that misoprostol not be used for induction of labor in women with prior Caesareans or major uterine surgery [R]
    • Use of the Foley bulb catheter has a uterine rupture rate close to that of women laboring spontaneously and has a VBAC success rate similar to that of women who have induced labor [B]. The intracervical catheter ripening method does not stimulate uterine contractions, which is an advantage for women with previous Caesareans [B]. The Society of Obstetricians and Gynecologists of Canada has endorsed the use of the Foley bulb catheter for cervical ripening for women with a low transverse uterine scar. ACOG has no statement either endorsing or discouraging mechanical dilators for cervical ripening in women attempting VBAC [R]."

If you or a loved one has suffered a severe injury or death as a result of a failure to inform of the risks of VBAC or a failure to provide proper care for labor and delivery, please contact for more information.

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