Vaginal Delivery After C-Section (VBAC) | Birth Injuries

A VBAC (or vaginal birth after C-section) refers to vaginal delivery of a baby by a woman who has previously had a C-section delivery. When a woman who previously had a C-section attempts to deliver a future baby vaginally, the attempt is called a trial of labor after Cesarean, or TOLAC. If the vaginal delivery is successful, the result is a VBAC.

Vaginal childbirth by mothers who have previously had a C-section is given this special name and designation because the prior uterine incision changes the risk analysis for future labor. VBAC is not a non-standard obstetrical procedure, and it can be a reasonable option for appropriately selected women. But a TOLAC does carry a small but serious risk of uterine rupture that has to be considered in deciding between a VBAC attempt and a scheduled repeat C-section.

At the turn of this century, the tide began moving away from VBACs after studies raised concerns about uterine rupture and hospitals and obstetricians adopted more restrictive policies. The national VBAC rate had increased from about 5% in 1985 to 28.3% in 1996 before dropping sharply. By 2006, the VBAC rate had decreased to 8.5%.

But the tide has turned again. VBAC rates have been increasing in recent years. National Center for Health Statistics data show that 15.5% of women with a previous C-section delivered vaginally in 2024, up from 15.1% in 2023. The rate has increased every year since 2016 so doctors are working to prevent VBAC injury.

The Risks of VBAC

The underlying reason why VBACs require additional attention is actually fairly easy to understand. It all has to do with the scar that a C-section leaves on the uterus. In a Cesarean delivery, the mother’s abdomen and uterus are surgically opened to allow delivery of the baby. Afterward, the surgical openings are closed. The uterine incision eventually heals, leaving a scar at the incision site.

The scar site from a prior C-section can become a major issue in any subsequent vaginal delivery attempt. Labor subjects the wall of the uterus to significant pressure. The prior uterine incision can be more susceptible to separation or rupture during labor, causing a rare and very dangerous obstetrical complication called uterine rupture.

The risk is not the same for every woman. The type of incision made in the uterus during the prior C-section is an important variable. A low-transverse uterine incision has the lowest risk of rupture. A classical or high vertical uterine incision presents a much greater risk and generally makes TOLAC inappropriate. Medical malpractice claims often stem from the doctor’s failure to appreciate the difference.

For women with one prior low-transverse C-section who undergo TOLAC, studies generally place the risk of uterine rupture at less than 1%. That sounds like a small number of VBAC injuries from uterine rupture, and it is. The problem is the potential severity of what happens when that rare complication actually occurs.

Uterine rupture is one of the worst complications you see during labor and delivery. A rupture of the uterine wall can block the supply of oxygen and nutrients to the baby. Deprivation of oxygen is one of the greatest threats to babies during pregnancy and childbirth. Oxygen deprivation can cause tragic brain injuries such as hypoxic-ischemic encephalopathy (HIE), often resulting in permanent mental or physical disabilities such as cerebral palsy.

Uterine rupture can also be dangerous for mothers. If not timely diagnosed and treated, a rupture of the uterus can cause massive internal bleeding, require blood transfusions or hysterectomy, and in the most serious cases threaten the mother’s life.

Why Would Anyone Choose a VBAC Instead of Another C-Section?

Why would anyone do a VBAC instead of a C-section? There are medical and personal reasons. A successful VBAC does have real advantages for the mother. There is generally less bleeding, a lower risk of infection, no abdominal surgery, and a shorter recovery period.

There are also potential benefits for women who plan to have additional children. Multiple C-sections can increase the risk of complications in future pregnancies, including placenta accreta, bowel or bladder injuries, and hysterectomy.

So not many people are arguing that doctors should never do a VBAC. The real problem is the wrong women in the wrong situation doing a VBAC.

Who Is a Good Candidate for TOLAC?

There is no single rule that determines whether a woman is an appropriate candidate for TOLAC. The decision requires the obstetrician to consider the mother’s prior delivery records, current pregnancy, medical history, and the resources available at the hospital.

One of the most important factors is the type of uterine incision used during the previous C-section. A prior low-transverse incision generally presents the lowest risk of uterine rupture. A classical uterine incision carries a substantially greater risk.

Other factors can include why the previous C-section was necessary, whether the mother has previously delivered vaginally or had a successful VBAC, the number of previous C-sections, fetal presentation, whether labor needs to be induced, other maternal or fetal medical conditions, and whether there is some other reason that vaginal delivery would be inappropriate.

The hospital matters too. A woman attempting TOLAC needs to be in a setting capable of responding to a life-threatening obstetrical emergency. If a uterine rupture occurs, there may be very little time to debate what to do next.

VBACs and Medical Malpractice

Medical negligence can occur in connection with VBACs in several different ways. Probably the most common form of VBAC-related malpractice is where a doctor improperly advises a mother to attempt TOLAC when she is not an appropriate candidate.

The American College of Obstetricians and Gynecologists (ACOG) has published guidance addressing the risks and benefits of VBAC and the factors that should be considered in deciding whether a woman is an appropriate candidate. Doctors can commit malpractice when they fail to properly assess a mother’s VBAC risk factors and attempt TOLAC in circumstances where it is not appropriate.

Another common type of VBAC malpractice occurs when doctors fail to recognize signs of fetal distress and wait too long before abandoning the TOLAC in favor of an emergency C-section. The question of when to intervene with an emergency C-section is present in every delivery. With TOLAC, however, doctors need to be particularly alert to changes in the fetal heart rate and other signs that may indicate uterine rupture or another dangerous complication.

The most dangerous type of medical malpractice that can occur in connection with VBAC is the failure to diagnose and respond to uterine rupture. The reason TOLAC requires special vigilance is that the C-section scar site on the uterine wall is more susceptible to rupture during labor.

A uterine rupture during labor and delivery presents an extreme emergency. When a rupture occurs, the baby may need to be delivered immediately by emergency C-section. Even a brief delay in diagnosing or responding to a uterine rupture during TOLAC can have devastating consequences for the baby and mother.

Fetal Heart Rate Changes During a VBAC

The one thing for sure is that, at a minimum, OBs, midwives, and labor and delivery nurses must know that management of a TOLAC patient in labor requires heightened vigilance.

One of the most important warning signs of uterine rupture can be a change in the fetal heart rate. Bradycardia, prolonged decelerations, recurrent abnormal decelerations, or other concerning changes in the fetal heart tracing require prompt evaluation.

An abnormal fetal heart rate does not automatically mean that the uterus has ruptured. There are many possible causes of fetal heart rate abnormalities. But in a woman with a prior C-section who is attempting TOLAC, uterine rupture has to be part of the differential diagnosis.

The hospital should be ready if the TOLAC needs to be converted into an emergency C-section.

Pitocin and Induction During TOLAC

Pitocin can be used in some women attempting TOLAC, but induction or augmentation changes the risk analysis. Excessive uterine contractions can increase stress on the prior C-section scar and can also cause fetal heart rate abnormalities.

This does not mean that every use of Pitocin during TOLAC is negligent. It means doctors and nurses need to carefully evaluate whether induction or augmentation is appropriate and closely monitor the contraction pattern and fetal heart rate.

A malpractice case can arise when Pitocin continues despite uterine tachysystole, a concerning fetal heart tracing, failure to progress, or other evidence that continuing the TOLAC is becoming dangerous.

What Is a TOLAC?

A TOLAC, or “Trial of Labor After Cesarean,” is the attempt to have a VBAC after the mother previously had a C-section.

The distinction matters. TOLAC describes the attempt at labor. VBAC describes the successful vaginal delivery. If the TOLAC is unsuccessful, the mother ultimately delivers by repeat C-section.

Informed Consent and VBAC

ACOG guidance emphasizes that the obstetrician should discuss the risks and potential benefits of both TOLAC and a scheduled repeat C-section. This allows the patient to make an informed choice.

Meaningful informed consent requires more than simply handing a patient a consent form. The mother needs enough information about the material risks, benefits, and alternatives to participate in the decision about whether to attempt TOLAC or have a scheduled repeat C-section.

Another related issue that often comes up in VBAC malpractice cases is the failure to obtain informed consent. Even though a VBAC is technically not a “surgical procedure,” the choice between TOLAC and repeat C-section involves risks that need to be discussed. Doctors are therefore obligated to explain the material risks and alternatives so the mother can make an informed decision. Failure to obtain meaningful informed consent can become an independent ground for a medical malpractice claim.

There was a case our lawyers saw once – not our case – where the mother asked the doctor whether she had ever lost a child during a VBAC. The doctor had very recently, but did not answer the question. That kind of omission can become part of an informed-consent claim because it involves information the mother specifically asked for before making her decision.

Medical Malpractice Laws and VBAC Rates

What is depressing is that receptivity to VBACs seems at least partly contingent upon the malpractice environment in which doctors practice.

Research has found that malpractice rules can influence obstetrical decision-making. Earlier research found that VBAC rates were significantly higher and C-section rates lower in states with caps on noneconomic damages. More recent research continues to find that the legal environment can influence physicians’ decisions about C-sections and how doctors respond to new information about VBAC.

A 2026 study published in Health Economics, for example, examined how malpractice rules affected physician responses to changing medical information about VBAC. The researchers found that the legal regime in which physicians practiced influenced how they responded to information about the procedure.

You would like to think that doctors delivering babies would be focused more on the safety of the baby and mother than the risk of medical malpractice claims for which they almost invariably have insurance coverage.

What Signs Can Indicate Uterine Rupture?

Uterine rupture can occur suddenly, and the signs are not identical in every case. Warning signs can include:

• fetal bradycardia or other significant fetal heart rate abnormalities
• sudden or severe abdominal pain
• vaginal bleeding
• changes in the contraction pattern
• loss of fetal station
• maternal rapid heart rate or low blood pressure
• other signs of internal bleeding or fetal distress

The fetal heart rate can be particularly important because an abnormal fetal tracing may be the first evidence that something has gone seriously wrong.

The key in a malpractice case is often not simply whether the uterus ruptured. Uterine rupture is a recognized complication of TOLAC. The real questions are whether the mother was an appropriate candidate for TOLAC, whether she and the baby were adequately monitored, whether the warning signs were recognized, and how quickly the medical team responded.

VBAC Verdicts & Settlements

Summarized below are verdicts and reported settlements from medical malpractice cases involving VBACs. These case descriptions are provided for informational purposes only. You cannot determine the settlement value of a VBAC malpractice case simply by comparing it to another case because the injuries, liability evidence, jurisdiction, economic damages, and future medical needs can be dramatically different.

• Moore v. St. Bernard Hospital (Illinois 2023) $19.025 million: A mother with a prior C-section attempts a VBAC at St. Bernard Hospital in Chicago. During labor, she is given Cervidil. The plaintiffs argue that the drug should not have been used in a VBAC patient and that hospital staff failed to adequately monitor and respond as the mother developed extreme pain. An emergency C-section is eventually performed, but the baby suffers severe hypoxic brain damage and dies at ten months old. A Cook County jury awards the family $19.025 million.
• Badawi v. Ohio State University Wexner Medical Center (Ohio 2023) $2.75 million: A mother with one prior C-section is approved for a TOLAC and receives Pitocin during labor. She develops fetal heart rate decelerations, maternal shoulder pain, tachycardia, and other warning signs before an emergency C-section is finally ordered. Doctors discover a uterine rupture, and the baby suffers severe hypoxic-ischemic brain injury and dies the following day. The Ohio Court of Claims finds that an emergency C-section should have been performed earlier and awards $2.75 million. The judgment is affirmed on appeal in 2024.
• A.J.J.T. v. United States (Tennessee 2020) $15.15 million: A mother who previously delivered by C-section elects to attempt a VBAC at Blanchfield Army Community Hospital at Fort Campbell. The lawsuit alleges that the medical providers failed to properly evaluate her individual likelihood of a successful VBAC and failed to adequately counsel her about factors that increased the risk of a failed TOLAC. The baby suffers severe hypoxic-ischemic brain injury resulting in cerebral palsy and lifelong neurological disabilities. After a federal bench trial, the judge finds that hospital personnel negligently evaluated and counseled the mother about VBAC and awards $15,153,488.
• Ziolokowski v Escobar (Pennsylvania 2018) $7.2 million: Mother’s first baby was delivered via emergency C-section after her labor stalled. Two years later she becomes pregnant again and her OB/GYN strongly encourages her to attempt VBAC. She is induced with Pitocin at full-term and attempts VBAC but her labor fails to progress after hours of pushing. Instead of abandoning the TOLAC and ordering an emergency C-section, her doctor continues the vaginal delivery, which takes several more hours. By the time the baby is eventually delivered, he is not breathing, but a neonatal resuscitation team is not on hand. By the time an emergency resuscitation team intubates the baby, he has suffered oxygen deprivation for nearly eight minutes, causing HIE, brain injury, and cerebral palsy. Mother sues her doctor and the hospital for negligently advising her to attempt VBAC and failing to be properly prepared for VBAC. A jury in Montgomery County awards $7.2 million.
• Kahnkari v Pombar (Illinois 2016) $11.2 million: A 34-year-old mother with two prior C-sections is advised to attempt VBAC. The baby is not in the optimal presentation, and the second stage of labor does not progress normally, but the doctor does not terminate the TOLAC effort. The doctor is eventually forced to use forceps to facilitate vaginal delivery, but the mother suffers a fourth-degree tear from her vagina to her rectum, resulting in a rectovaginal fistula. She sues the doctor for negligently advising her to attempt VBAC when she was not an appropriate candidate in light of the baby’s presentation. A jury in Chicago awards $11.2 million in damages.
• Pike v Hodges (Idaho 2016) $1.4 million: A mother delivers her first baby via C-section but has a successful VBAC with her second baby. With the advice of her doctors, she attempts VBAC again for her third baby. Although the VBAC successfully delivers the baby without harm, her uterus partially ruptures at the C-section scar site at some point during the delivery. Despite symptoms and the fact that the delivery was a VBAC, her doctors fail to timely diagnose the uterine injury, and it leads to an infection in her abdominal cavity.
• French v Rosencranz (Indiana 2010) $1 million: After delivering her first baby via emergency C-section, the mother’s doctors plan to attempt VBAC for delivery of her second baby despite a history of complications with her prior pregnancy. The VBAC attempt goes wrong and ultimately has to be abandoned after a uterine rupture occurs at the C-section scar site. The baby is eventually delivered via emergency C-section but not before suffering significant oxygen deprivation. The baby is eventually diagnosed with cerebral palsy. Mother files a malpractice suit alleging, among other things, that doctors never obtained informed consent for the VBAC. The case is ultimately settled out of court for $1 million.
• Stanziano v. Miami Valley Hospital (Ohio 2009) $30.9 million: After vaginal delivery of her first baby and C-section for her second baby, the mother is advised by doctors that she is an appropriate candidate for VBAC with her third baby. She is admitted to the hospital for a full-term VBAC attempt and given Pitocin to accelerate contractions. While under the supervision of nurses, she suffers a severe uterine rupture at her scar site. The placenta detaches, and the baby is outside the uterine cavity when he is eventually delivered via emergency C-section. The baby suffers hypoxic-ischemic brain injury and severe cerebral palsy. Her lawyers file a birth injury medical malpractice case alleging negligent management of the VBAC and failures in monitoring and response by hospital personnel. A Montgomery County, Ohio jury awarded approximately $30.9 million in damages.

What Is a VBAC Malpractice Case Worth?

The value of a VBAC malpractice case depends primarily on the injury caused by the negligence. The highest-value cases usually involve catastrophic birth injuries caused by oxygen deprivation, including HIE and cerebral palsy, maternal hysterectomy or other permanent injuries, or the death of the baby or mother.

In a severe brain injury case, the largest component of damages may be the cost of caring for the child over a lifetime. Future medical care, therapy, equipment, attendant care, lost earning capacity, and other economic losses can reach millions of dollars.

Liability and causation are equally important. Uterine rupture by itself does not establish malpractice because rupture is a recognized risk of TOLAC. The plaintiff still needs to show that the medical team made a mistake, such as selecting an inappropriate candidate, negligently managing Pitocin, failing to recognize fetal distress, failing to diagnose uterine rupture, or waiting too long to perform an emergency C-section, and that this mistake caused the injury.

Miller & Zois Can Help With Your VBAC Malpractice Case

If you or your baby has been injured in a VBAC and you think the doctors may have made a mistake, contact the birth injury malpractice lawyers at Miller & Zois for help. We can review your medical records and help you determine whether or not medical malpractice may have occurred. Call us today at 800-553-8082 or request an online consultation.