A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective

 

This article is part of A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations, a collection of resources that address the most common and pressing questions women may have about their birth choices. View all sections in the guide, including a link to the authors, on the index page.

By Janelle Komorowski

In recent years, it has become harder to find physicians and hospitals willing to allow women to attempt a vaginal birth after cesarean (VBAC), also called a trial of labor after cesarean (TOLAC). The biggest risk attempting a VBAC is that the uterine scar may separate during labor. This is called a uterine rupture.

Although uterine rupture is not common, it can be very serious for both the mother and baby. Most hospitals in the United States now require that anesthesia, an operating room, and a surgeon be immediately available when a woman is attempting a VBAC.

Although this sounds like a good policy, it has caused some hospitals to stop allowing VBACs because they do not have adequate staff. The National Institutes of Health (NIH) VBAC Consensus Statement raises an important question: how often does uterine rupture happen, compared with other emergencies during labor?

Every labor carries a small risk of an unexpected emergency happening, so should a surgeon, anesthesia, and operating room have to be immediately available for all labors? Or should planned VBACs be treated like other labors, where the physician is nearby, but does not have to remain inside the hospital during the entire labor?

Since hospitals don’t require a surgeon and anesthesiologist to be present during every labor, the NIH is asking whether the risk of VBAC has been emphasized more than other childbirth emergencies. These emergencies include placental abruption, where the placenta separates from the uterus before the baby is born; cord prolapse, where the umbilical cord is coming out in front of the baby’s head; and shoulder dystocia, where the baby is stuck because its shoulders are too wide to fit through the pelvis.

To understand how often such emergencies happen during labor or birth, let’s look at the following table:

Table 1.
Uterine Rupture1 Placental Abruption2 Umbilical Cord Prolapse3 Shoulder Dystocia4
7-8 out of every 1000 VBAC attempts 11-13 out of every 1000 labors 14-62 out of every 1000 labors 6-14 out of every 1000 labors

The next table shows the risk of a baby dying as a result of one of these emergencies:

Table 2.
Uterine Rupture Placental Abruption Umbilical Cord Prolapse Shoulder Dystocia
6 out of every 100 uterine ruptures will result in a baby’s death 1.25 out of every 750 placental abruptions will result in a baby’s death 91 out of every 1000 babies with cord prolapsed will die 1 out of every 1000 babies with shoulder dystocia will die

The truth is, in a low-risk woman, the risk of the uterus rupturing is about the same as the risk of any serious birth emergency happening. To be considered low risk, you should have:

  • One horizontal scar on your uterus (the scar on your skin may be vertical or horizontal)
  • A labor that starts on its own
  • No use of pitocin during labor, or prostaglandin to soften the cervix
  • At least 18 months since the cesarean birth

What are the risks of a planned repeat c-section compared to a planned VBAC? We don’t have a lot of evidence to help us decide, but the risks seem to be different for the mother than the baby. About 13 out of every 100,000 women who have a cesarean birth will die from surgery complications. Only 4 out of every 100,000 women who attempt a VBAC will die as a result.

A repeat cesarean birth may be safer for baby. NIH figures show that 50 babies out of every 100,000 born by c-section will die. 130 out of every 100,000 babies born to mothers having a trial of labor will die. However, these numbers come from studies that included all women who had a trial of labor, even if they were high risk, had prostaglandins to soften the cervix, or pitocin during labor. In other words, these numbers do not distinguish lower-risk from higher-risk VBAC attempts.

We know that softening the cervix with prostaglandins or using pitocin during labor increases the risk of uterine rupture. If a woman does not receive prostaglandins or pitocin, the risk of her baby dying during a trial of labor is probably lower.

Worth noting is that most babies who are born after a uterine rupture do not have serious long-term problems if the baby is delivered immediately after the rupture.

The NIH is encouraging doctors and hospitals to find ways to make VBAC more available for women. One of the ways this can be done is to recognize that the absolute risks of VBAC are about the same as the risk of any other serious complication during labor and birth. Understanding these risks can help you plan a safe VBAC for your next birth.

 

References

1. National Institutes of Health. NIH Consensus Development Conference: Vaginal Birth After Cesarean: New Insights, draft statement. March 8–10, 2010. Retrieved 05/12/10 from: http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf

2. Ananth CV, Wilcox AJ. Placental abruption and perinatal mortality in the United States. American Journal of Epidemiology Vol. 153, No. 4 : 332-337.

3. Murphy DJ, Mackenzie IZ. The mortality and morbidity associated with umbilical cord prolapse. British Journal of Obstetrics and Gynaecology. 1995 Oct;102(10):826-30.

4. Mackenzkie IZ, Shah M, Lean K, DuttonS, Newdick H, Tucker DE. Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstetrics and Gynecology. 2007 Nov;110(5):1059-68.

5. Vaginal Birth After Cesarean: New Insights, Structured Abstract. March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/vbacuptp.htm

 

Additional Reading

Avatar of Cara TerreriAbout Cara Terreri
Cara began working with Lamaze in 2004, two years before becoming a mother. Three kids later, she's a full-fledged healthy birth advocate and the Site Administrator for Giving Birth with Confidence. Most recently Cara began study to become a Lamaze Certified Childbirth Educator and DONA certified doula (learn more about her services at www.SimpleSupportBirth.com). She continues to stand in awe of the power and beauty in pregnancy and birth, and enjoys helping women discover their own power and joy in the journey to motherhood.

Comments

  1. This is excellent…I’m glad to see the statistical data juxtaposed with the issues of safety for all women giving birth. For my second child I ended up having an unexpected c-section and had to give birth in what could fairly br called the OR’s broom closet…
    Did have a sucessful VBAC with my third and had Pitocin (after much debate and consideration) purely so there would be an anesthesiologist there “in case.”
    The whole process in the US is just in a sad state…

Trackbacks/Pingbacks

  1. [...] This post was mentioned on Twitter by Claire Bracey, Cynthia Jackson. Cynthia Jackson said: A Woman's Guide to VBAC: Putting Uterine Rupture into Perspective — Giving Birth with Confidence http://t.co/QwnSFB8 [...]

  2. [...] A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations compares uterine rupture with other potential complications. You are more likely to experience a placental abruption, a cord prolapse or a shoulder dystocia (not associated with previous c-section) during your vbac than a uterine rupture. Your baby is also more likely to die from the placental abruption or cord prolapse than from a uterine rupture. [...]

  3. [...] A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective [...]

  4. [...] Wednesday’s post, I referenced Putting Uterine Rupture Into Perspective, and I wanted to list it again, as it is an excellent resource on this most important and [...]

  5. [...] In my honest opinion, I feel like a woman’s best option for a VBAC (Vaginal Birth After Cesarean) is by going with midwives (click for more info on what a midwife is). In our area, from what I understand, the Certified Nurse Midwives at the hospital will not attend VBAC clients because they are too “high risk” for them. For an idea of the relative risks in a VBAC versus other rare, but serious, risks in childbirth and labor (for ANY laboring woman), I really like this blog’s information. [...]

  6. [...] A referenced blog about this puts this information in a table to clearly see the comparisons : A woman’s guide to VBAC: Putting risk into perpespective   Looking at the information presented to us, particularly received information from a [...]

  7. […] In recent years, it has become harder to find physicians and hospitals willing to allow women to attempt a vaginal birth after cesarean (VBAC), also called a trial of labor after cesarean (TOLAC). The biggest risk attempting a VBAC is that the uterine scar may separate during labor. This is called a uterine rupture. http://givingbirthwithconfidence.org/2010/10/a-womans-guide-to-vbac-putting-uterine-rupture-into-per… […]

  8. […] In other words although having a VBAC increases the particular risk attached to birth is uterine rupture, compared to the risks quoted for other obstetric emergencies, such as shoulder dystocia, cord prolapse etc, it is about the same.  All women having their first baby are quoted as having the same degree of risk when it comes to the possibility of an obstetric emergency. A referenced blog about this puts this information in a table to clearly see the comparisons : A woman’s guide to VBAC: Putting risk into perpespective […]

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