Improper Patient Selection for a Trial of Labor
After your delivery went wrong, you may have started asking a harder question. Not just what happened, but whether you should ever have been put in that situation. You agreed to try for a vaginal birth after your cesarean because a doctor recommended it. You trusted that recommendation. Now you wonder if your own medical history made that plan a poor and dangerous fit.
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Article written by Brendan Lupetin, Esq. Brendan is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
We are dedicated to helping mothers and infants that have been injured due to negligence during childbirth.
This article explains how doctors are supposed to decide who is a good candidate for a trial of labor after cesarean. It explains who should not be offered one at all. And it explains what it means when a doctor steers a woman toward a delivery plan that was wrong for her.
A trial of labor is a choice that must be matched to the patient
A trial of labor after cesarean, often called TOLAC, is an attempt to deliver vaginally after a prior C-section. A successful trial ends in a vaginal birth after cesarean, or VBAC.
For many women, a trial of labor is a reasonable and safe option. The American College of Obstetricians and Gynecologists supports it for appropriate candidates. But that last phrase carries all the weight. A trial of labor is not safe for everyone. The job of the doctor is to sort out who is a good candidate and who is not. When that sorting is done carelessly, a woman can be placed at a risk she never should have faced.
Who is generally a good candidate
ACOG describes the typical good candidate in clear terms. Most women with one prior cesarean delivery through a low-transverse incision are candidates for a trial of labor and should be counseled about it and offered the option.
A low-transverse incision is a side-to-side cut across the lower part of the uterus. It is the most common type, and it is the type least likely to tear in a later labor. Other factors improve the odds of a safe and successful trial. They include a prior vaginal delivery, a labor that begins on its own, and a reason for the first cesarean that is not likely to repeat.
Who should not be offered a trial of labor
This is where careful patient selection matters most. ACOG identifies women who are at high risk of uterine rupture and who are generally not candidates for a planned trial of labor. They include:
- Women with a prior classical or T-shaped uterine incision, rather than a low-transverse one. These incisions involve the upper, thicker, more active part of the uterus and carry a much higher risk of rupture.
- Women who have had a prior uterine rupture. A uterus that has torn once is far more likely to tear again.
- Women with prior extensive surgery on the upper part of the uterus.
- Women for whom a vaginal delivery is unsafe for another reason, such as a placenta that covers the cervix.
For these women, a trial of labor is not a balanced choice between two reasonable paths. It is an exposure to a serious and foreseeable danger. The standard of care is to identify these patients and recommend a planned repeat cesarean instead.
The type of incision is not the same as the type of skin scar
Many women carry a low, horizontal scar on their skin and assume the cut on the uterus matched it. That is not always true. The skin scar and the uterine incision are separate. A surgeon can make a low skin incision and still cut the uterus differently if the situation demands it.
This is why the records from the first cesarean matter so much. The operative report from that first delivery describes exactly how the uterus was cut. A doctor counseling a woman about a trial of labor is expected to know what that report says. Assuming a low-transverse incision without checking is a shortcut that can have severe consequences.
Counseling is part of candidate selection
Selecting the right candidate is not only about a yes-or-no decision. It is also about an honest conversation. ACOG stresses shared decision making. A woman is supposed to be told her individual likelihood of a successful vaginal birth and her individual risk of uterine rupture. That conversation, and the decision that follows, should be documented.
A woman cannot give true consent to a trial of labor if she was never told the real risks, or if she was pushed toward one path without an honest discussion of the other. When the counseling is incomplete or one-sided, the choice was never really hers.
Where care goes wrong
In cases involving a trial of labor, improper patient selection is one of the failures we look for first. At Lupetin & Unatin, we review the operative report from the prior cesarean to see how the uterus was actually cut. We look at whether the doctor accounted for a prior rupture or prior uterine surgery. We look at whether the woman was told her real, individual risk, or only a reassuring summary. And we look at whether a planned repeat cesarean should have been recommended instead.
When a woman who was never a safe candidate is guided into a trial of labor and a rupture follows, the injury did not begin in the delivery room. It began with a decision made weeks earlier.
Frequently Asked Questions
The answer is in the operative report from your first cesarean. That document describes exactly how the surgeon cut the uterus, which is not always the same as the scar you see on your skin. You have a right to your medical records, and our office can help you obtain the complete file, including that operative report. Knowing what type of incision you had is often the first step in understanding whether a trial of labor was an appropriate recommendation.
Not on its own. A choice is only a real choice if it is informed. If you were never told that your history put you at high risk, or if you were never offered an honest comparison with a planned repeat cesarean, then the decision was not truly yours to make. The standard of care requires honest, individualized counseling. We examine what you were actually told, and what the records show you were told.
An initial review and consultation with our office is free. We handle birth injury and medical malpractice cases on a contingency fee, which means you owe no attorney fee unless we recover compensation for your family. The first step is simply a conversation, with no obligation, so you can understand whether your delivery plan should ever have been recommended.
How Lupetin & Unatin can help
At Lupetin & Unatin, we concentrate on catastrophic birth injury and medical malpractice cases in Western Pennsylvania. Attorney Brendan Lupetin and attorney Greg Unatin keep the firm’s caseload small so that families work directly with a partner who understands the medicine and the record.
Our firm has recovered record verdicts and settlements in catastrophic injury and medical malpractice cases, and we bring that experience to every birth injury matter we take.
A patient selection case is built on the prenatal records, the prior cesarean operative report, and the counseling notes, or the absence of them. We obtain those documents. We work with obstetricians and maternal-fetal medicine specialists who can explain whether a reasonable doctor would have offered a trial of labor at all. If a woman was steered into a delivery plan that her own history made dangerous, we are prepared to show it.
Talk to a Pittsburgh Birth Injury Attorney
If your baby or your family was harmed during a trial of labor after cesarean, the attorneys at Lupetin & Unatin, LLC are here to help you find answers. We offer free, confidential consultations, and we handle medical malpractice and birth injury cases on a contingent fee basis. You pay no attorney fee unless we recover compensation for you.
It is important not to delay. Pennsylvania law limits the time you have to file a claim.