|Posted on April 26, 2016 at 10:18 AM||comments (60)|
This was in posted April 2012 - updated April 2016
Uterine rupture is a topic that came up when I was pregnant with Otter that I was not ready to allow into my consciousness until she was safely in our arms. After enough time had passed and we have proven to ourselves that homebirth can be a safe option when a person is healthy and low risk, I am ready to write about it.
I gave Stephanie Stanley, former facilitator of the East Valley ICAN group, byline credit for this because I am using her research from a uterine rupture presentation she did at a meeting for my post today. ICAN, the International Cesarean Awareness Network, is a non-profit organization that strives to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, as well as educate about Vaginal Birth After Cesarean (VBAC) and options for what is called a "gentle cesarean" where the event is honored as a birth even though it's via a surgery. ICAN’s goal is to see a healthy reduction of the cesarean rate that is patient-driven. By providing education and support, they hope that more women making evidence based, risk appropriate childbirth decisions will lead to an overall reduction in the rate of cesareans performed.
Uterine rupture seems to be the leading reason why care providers are hesitant to allow a mother to have a trial of labor (TOL) after a previous cesarean. In Arizona, a licensed midwife or certified professional midwife can attend a homebirth with a mom who is striving to have a VBAC only if the mother meets certain criteria. Arizonana for Birth Options is leading a grassroots efforts to change this so that as per the ICAN vision, women living here can make evidence based and risk appropriate decisions. They want all options to be available: for a hospital birth if mom feels that is the best option, or a homebirth if both mom and midwife agree that they are a good candidate for VBAC.
Uterine rupture is defined as an anatomic separation of the uterine muscle with or without symptoms. What this means for baby is that the uterus ceases to function as a sealed protective container from the rest of the blood and organs surrounding the baby. The function of the placenta and umbilical cord may also be compromised. Mom is subject to blood loss and shock. A decision also has to be made about repairing the uterus or performing a hysterectomy.
Another term used when talking about uterine rupture is “dehiscence”. A dehiscence is the splitting or incomplete opening of the cesarean scar. It can happen without complication for mom or baby and sometimes it is only discovered after the delivery. It is also called a “window” by some care providers.
As it turns out, while uterine rupture is a consideration when you are preparing for a birth after a cesarean, it's not the only one your care provider should be having a conversation about. You can read THIS post to see where the risk for uterine rupture falls in comparison to other risks of pregnancy and labor.
So what does the research say?
Here is the overarching conclusion: anyone can be at risk, whether you have an unscarred or scarred uterus. At most, your risk rate is 2%. 2 percent! Why then is it that this is such a big deal? I believe it lies with the potentially devastating circumstance a family will find themselves in if the uterus does rupture. While 98% of the population may have a successful VBAC, the worst case scenario of a uterine rupture is the loss of the baby and possibly a hysterectomy for mom which makes future pregnancies impossible. Another point to ponder is that the statistics listed below are close to other statistics for labor emergencies, such as placenta accreta, placental abruption, miscarriage; for a longer list click here.
Statistics for the risk of uterine rupture – see links at the end of this post for references:
VBAC: .5% - .7%
VBA2C: 1.7% (vaginal birth after 2 cesareans)
VBAMC: 1.2% (vaginal birth after multiple cesareans)
Previous VBAC: .4% - .5% (if you had a previous successful VBAC)
VBAC + Augmented labor: .9% (stats for first attempt)
VBAC + Induced labor: 1% (stats for first attempt)
Here is a link to the comparison of risk rates for VBAC, CBAC (a cesarean birth after a trial of labor) and ERC (elective repeat cesarean) http://www.sciencedirect.com/science/article/pii/S0002937808004213
The risk factors when considering whether or not to do a trial of labor after a cesarean are:
The type of scar you have: the most favorable is a low transverse scar. Classical T-shaped scars, vertical scars or high uterine scars are said to have a higher risk of rupture.
Induction of labor using cervical ripening agents, i.e., Cytotec, Cervidil: the prostaglandins that soften the cervix may also soften the scar tissue. In addition, ripening agents can cause uterine hyperstimulation, meaning contractions that are much more intense and frequent than the uterus is designed to withstand in the course of an unmedicated labor.
More than one cesarean: as you can see from the statistics above, there is a slight increase of risk.
Among factors that are disputed in medical literature are:
- Age of mother: if a mother is over 30 she may be considered at higher risk for uterine rupture.
- Obese women
- Size of baby: more than 8 pounds, 14 ounces
- Post-term baby: 40+ weeks gestation from last menses
To compare, here are the stats and risk factors for an unscarred uterus: “The normal, unscarred uterus is least susceptible to rupture. Grand multiparity, neglected labor, malpresentation, breech extraction, and uterine instrumentation are all predisposing factors for uterine rupture. A 10-year Irish study by Gardeil et al showed that the overall rate of unscarred uterine rupture during pregnancy was 1 per 30,764 deliveries (0.0033%). No cases of uterine rupture occurred among 21,998 primigravidas, and only 2 (0.0051%) occurred among 39,529 multigravidas with no uterine scar.
A meta-analysis of 8 large, modern (1975-2009) studies from industrialized countries revealed 174 uterine ruptures among 1,467,534 deliveries. This finding suggested that the modern rate of unscarred uterine rupture during pregnancy is 0.012% (1 of 8,434). This rate of spontaneous uterine rupture has not changed appreciably over the last 40 years, and most of these events occur at term and during labor. An 8-fold increased incidence of uterine rupture of 0.11% (1 in 920) has been noted in developing countries. This increased incidence of uterine rupture has been attributed to a higher-than-average incidence of neglected and obstructed labor due to inadequate access to medical care. When one assesses the risk of uterine rupture, this baseline rate of pregnancy-related uterine rupture is a benchmark that must be used as a point of reference.”
If you choose to have a VBAC, or realistically for any woman in labor since the statistics show she has a slight risk, here are the signs that may help you recognize that a uterine rupture is occurring or may have occurred:
- Excessive vaginal bleeding
- Extreme pain between contractions – these may or may not be felt through an epidural block, though due to severity of pain it’s possible they may be felt
- Contractions that slow down or become less intense
- Abdominal pain or tenderness
- Baby’s head moves back up the birth canal
- Bulge in the abdomen, bulge under the pubic bone, or pressure on the bladder where the baby’s head may be coming through the tear in the uterus
- Sharp onset of pain at the site of the previous scar
- Uterus becomes soft
- Shoulder pain
- Heart decelerations in the baby
- Maternal tachycardia (rapid heart rate) and hypotension (low blood pressure)
If you have a true uterine rupture, then an emergency cesarean will be required. A Chandler doctor told the ICAN group that the care provider has 5 – 7 minutes to get the baby out safely, although in reading for this post I saw some estimates as 10 – 37 minutes.
According to a 2010 National Institutes of Health study, there have been no maternal deaths in the US due to uterine rupture. Overall, 14 – 33% will need a hysterectomy. 6% of uterine ruptures result in perinatal death, and for term babies this risk was put at less than 3%. **
If you do have a uterine rupture, it will have an effect on your future pregnancies. Each cesarean a mother has increases the risk for future complications of cesarean surgery. If you have a hysterectomy, you will not be able to carry any more children. In today’s medical climate, a uterine rupture will most likely result in all future pregnancies being delivered via repeat cesarean.
There are a lot of points to ponder as a new mom or as a mom considering a VBAC. Our Bradley® mantra is: Healthy Mom, Healthy Baby. We teach that as long as you make all your decisions with those two goals in mind, you are likely to make the choices that have a positive outcome for both Mom and Baby.
What are your thoughts on VBAC and/or uterine rupture?
**NOTE: Stephanie’s presentation called out these statistics as inflated as the Landon study (2004) included women who had pre-labor stillbirths included in the statistics. IN other words, women whose babies had passed away before labor and still delivered via VBAC rather than choosing a repeat cesarean were counted in the perinatal death statistics. Please read Henci Goer’s analysis for more information
For the resource list, click here.
The material included on this site is for informational purposes only.
It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation. This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.
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The Bradley Method® includes a class on how to handle those “bumps” so that parents are at least aware of what the variations and complications are, what the possible reasons are for them, and the options available to them should they encounter these situations. We also encourage our students to do additional reading on these situations – it is never good enough to take an instructors word on these, especially for the decisions that impact their child. It is important for students to decide how they would probably want to handle these possible variations and complications while there is time to consider all the options and make a thoughtful choice that they can fall back on in case a moment of decision and/or urgency does arise.
In addition, we encourage our couples to discuss their options with their care team. Each provider has a their own set of policies and protocols based on their experience as practitioners. It is important that your preferences match with the practice your care team employs so that you are able to work with them and have their support for your choices.
Our goal is to inform the parents, give them a basis for a conversation, encourage them to either write down their decisions or make a mental note, then file that information away and turn the focus back to having a normal, uncomplicated, low-risk pregnancy and labor.
Here is a great resource to help a couple do some emotional preparation for labor ~ http://www.birthingnaturally.net/encourage/encourage.html
There are several questions and thoughts to consider as you prepare for different aspects of pregnancy and labor. Again, the goal is to help you come to some conclusions, and then set forth an action plan if through the exercises you realize that there are any unresolved issues or aspects of your pregnancy and labor that you want to discuss with your care team. Once you face the different possibilities or the fears you might have and make a plan, the idea is to file away the information and focus on having the pregnancy and birth that you want for your family.
The one topic that is so hard to talk about and the situation that none of us want to face is pregnancy loss. There is an outside possibility that this joyous time of preparation and anticipation sometimes ends with a miscarriage, stillbirth, or the loss of a healthy child due to unforeseen circumstances or events.
It is hard for me to get through this part of class without getting emotional. It is one of the fears I have and that I try to turn over in prayer during our pregnancies. If it is hard for me as the instructor, I can only imagine it is something hard for our students to face and talk about, too.
I provide this resource list today with the prayer that you (or anyone close to you) will never have to use it. On what I hope and pray is a very outside chance that something unthinkable happens, here are several organizations and providers that offer counseling, comfort and free services to support the grieving family.
Arizona Perinatal Loss Bereavement Resource
Banner Desert Medical Center
1400 S. Dobson Road, Mesa, 85202
Provides a network of support for those experiencing a pregnancy or infant loss. This resource gives parents a statewide network of support, current bereavement literature on a variety of topics, educational opportunities and resources in the community, state and national level.
The Compassionate Friends
The Compassionate Friends assists families toward the positive resolution of grief following the death of a child at any age and to provide information to help others be supportive. They offer a safe place for bereaved parents, grandparents, and siblings to meet and talk freely about your child and your grief issues.
The M.I.S.S. Foundation provides immediate and ongoing support to grieving families through community volunteerism opportunities, public policy and legislative education and programs to reduce infant and toddler death through research and education.
M.E.N.D. Mother's Enduring Neonatal Death
M.E.N.D. (Mommies Enduring Neonatal Death) is a Christian, non-profit organization that reaches out to families who have suffered the loss of a baby through miscarriage, stillbirth, or early infant death.
HAND Helping After Neonatal Death
HAND is a resource network of parents, professionals, and supportive volunteers that offers a variety of services throughout Northern California and the Central Valley.
SHARE Share Pregnancy and Infant Loss Support, Inc
The mission of Share Pregnancy and Infant Loss Support, Inc. is to serve those whose lives are touched by the tragic death of a baby through early pregnancy loss, stillbirth, or in the first few months of life.
Now I Lay Me Down To Sleep
They offer the free gift of professional portraiture and remembrance photography to parents suffering the loss of a baby. “The NILMDTS Foundation is there for parents and families to help aid them in their Healing, bring Hope to their future, and Honor their child. It is through Remembrance that a family can truly begin to heal.” They feel that these images serve as an important step in the family’s healing process by honoring their child’s legacy.
Placenta Encapsulation – Wendy Diaz, PBi™ PES
Her encapsulation services are free for bereaving mothers. Wendy will also add herbs to the capsules that help dry up the milk supply.
Empty Cradle, Broken Heart: Surviving the Death of Your Baby
by Deborah L. Davis, Ph.D.
Product Description from Amazon.com:
The heartache of miscarriage, stillbirth, or infant death affects thousands of U.S. families every year. Empty Cradle, Broken Heart offers reassurance to parents who struggle with anger, guilt, and despair after such tragedy. Deborah Davis encourages grieving and makes suggestions for coping. This book strives to cover many different kinds of loss, including information on issues such as the death of one or more babies from a multiple birth, pregnancy interruption, and the questioning of aggressive medical intervention. There is also a special chapter for fathers as well as a chapter on "protective parenting" to help anxious parents enjoy their precious living children. Doctors, nurses, relatives, friends, and other support persons can gain special insight. Most importantly, parents facing the death of a baby will find necessary support in this gentle guide. If reading this book moves you to cry, try to accept this reaction. Your tears merge with those of other grieving parents.
A purpose of this book is to let bereaved parents know that they are not alone in their grief. With factual information and the words and insights of other bereaved parents, you can establish realistic expectations for your grief. Empty Cradle, Broken Heart is meant to help you through these difficult experiences by giving you things to think about, providing suggestions for coping and encouraging you to do what you need to survive your baby's death. Whether your baby died recently or long ago, this information can be useful to you.
Disclaimer: The material included on this blog and this site is for informational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation. This blog and this site contain information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog and this site do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.