Insurers set criteria for VBAC coverage.(News)

The malpractice insurance crisis is prompting a small number of professional liability insurers to institute strict standards for performing vaginal birth after cesarean section.

And an Oklahoma insurer last month has gone as far as excluding coverage for the procedure, citing a high number of claims associated with allegations of failure to perform a timely cesarean.

For its part, Northwest Physicians Mutual Insurance Company in Oregon still covers vaginal birth after cesarean section (VBAC), but it instituted a requirement in late 2003 that physicians and nurse-midwives who provide obstetric care must submit verification that the hospital where they practice is able to meet specific criteria. To continue to be covered to perform VBACs, physicians and the facilities in which they perform VBACs have to demonstrate that a physician capable of monitoring and performing an emergency cesarean delivery is present in the hospital or on the hospital's campus throughout active labor.

The insurer bases its certification on a practice bulletin issued by the American College of Obstetricians and Gynecologists (ACOG), which recommends that a physician capable of monitoring labor and performing an emergency cesarean be "immediately available" throughout active labor.

"Given the associated risks and elective nature of performing this procedure, coverage for the performance of VBACs will only be offered under specific criteria," William Gallagher, M.D., president and chair of Northwest Physicians Mutual, said in a letter to physicians.

For N. Michelle Sang, M.D., an ob.gyn. in Portland, Ore., who is insured through Northwest Physicians Mutual, this change means she's become much more selective about providing VBACs.

Since she is affiliated with two hospitals, it's not practical to expect to be in one hospital for a patient's labor and delivery, so Dr. Sang and her colleagues in the practice have patients sign a contract acknowledging they might not be able to undergo a trial of labor.