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"Many women are willing to take the risk, and the hospitals' stance has become a charged issue, part of a larger battle over who controls childbirth. Some women say their freedom of choice is being steamrolled by obstetricians who find Caesareans more lucrative and convenient than waiting out the normal course of labor. Doctors say their position is based on concern for patients' safety. "

Ahhh....the PERFECT example of the impact of legal issues and financial issues on medicine.

Believe me, this issue has NOTHING to do with a repeat C/S being more "lucrative" to Physicians, and EVERYTHING to do with safety.

In the modern era, with the almost universal use of regional anesthesia (Spinal or Epidural anesthesia) for C/S that are non-emergent, the true incidence of major morbidity and/or mortality from elective C/S has become negligent or non-existent. With attempted VBAC, there is a CERTAIN risk that approaches 1% by most estimates of a potential CATASTROPHIC outcome for either the mother, fetus or both.

In the current medicolegal environment, as a physician, which route would you choose?

The primary problem with VBAC is COVERAGE IN HOUSE when women are in labor...the ONLY way I would let my wife labor as a VBAC is if BOTH the obstetrician AND Anesthesia provider (preferably and Anesthesiologist) were IMMEDIATELY AVAILABLE... and that means IN HOUSE, and NOT OTHERWISE OCCUPIED.

No one in medicine presently gets reimbursed by insurance carriers for "being available", or staying "in house"...if it's 0200, and your wife comes in to the facility as a VBAC in labor, am I expected to come in to the facility and stay there FOR NOTHING so you can have the choice to attempt VBAC to ensure it's safe? If it's in the middle of the day, am I supposed to cancel elective OR cases to make an anesthesia provider IMMEDIATELY available to respond to the mother attempting VBAC who has an emergency? Who pays for that? Who pays for the immediately available scrub tech and circulating RN?

Legally, as a physician if I know that elective C/S is inherently safer (regardless of the patients feelings) than VBAC, and if I am legally liable for a potential lawsuit in the multiple millions of dollars for a bad outcome secondary to a catastrophic UNANTICIPATED, and UNPREVENTABLE event such as uterine rupture, am I obligated to acquiesce to the patients wishes?

Listen folks...anyone that is anticipating VBAC that is reading this thread, I encourage you to ask the following questions:

1. Will the obstetrician be IN HOUSE and immediately available?
2. Will there be an anesthesia provider IN HOUSE and immediately available?
3. Does the hospital make provisions to have immediate OR availablity with proper staffing 24/7/365?

If the answer to any of these questions is no, then you are rolling the dice.