When you are the statistic: Uterine rupture loss

When you are the statistic: Uterine rupture loss

Above: “I donated my wedding dress to be made into gowns for deceased infants to be buried in. I had pictures done in my dress before I donated it. This is one of my favorites.” – Kaila Flory

Kaila Flory lost her baby to a uterine rupture eight months ago. She recently reached out to me and gave me permission to share her story and pictures of her son Beau.  She is currently raising money to purchase Cuddle Cots in Beau’s memory. Cuddle Cots are refrigerated bassinets that enable loss parents to spend more time with their child. While t-shirt sales end on April 22, 2016 at midnight EST, you can donate anytime. Even just $10 will get her closer to her goal. Buy a t-shirt and/or donate here.  Connect with her Facebook page here

Women who have had uterine ruptures and lost their babies have endured some of our greatest fears. But they are part of our community as well. When the VBAC Facts Community, a Facebook group, was opened to the public, we welcomed and embraced the parents who joined us after their loss. Often they felt like they were no longer part of the birth community. They didn’t know where they fit in. They felt isolated and yet they wanted to share their story. We had many loss moms as members and many parents who were planning VBACs who wanted to hear their stories.

What follows is Kaila’s story.

Kaila Flory’s first son was born by cesarean after being induced for intrauterine growth restriction. When she was 38 weeks and a few days pregnant with her second son, 26-year-old Kaila started having cramps around 1 a.m. “Luckily I had stayed with my dad, so I was not alone with my 3 year old. My husband was at Basic Training. Then a contraction came. Ok, I thought, this is real. It’s time. Then another came. It had only been like a minute or 2. Then severe pain came over my abdomen, and my face and limbs went numb.”

Her father called the paramedics and she was rushed to the hospital, where a STAT c-section was ordered. She nearly bled to death.

Beau-&-Kaila

“This is the only photo I have of myself holding him. I requested people to not take my photo, but I am so glad my best friend took this with her phone. THIS is what raw, real pain looks like. This is why I want people to have Infant Loss Awareness.”

She says:

While I wholeheartedly believe that women should be given the option for VBACs, I also believe women need to consider their child’s health as the most important in this situation. I would have loved to have 3 weeks of pain just to have my son in my arms. I know it is not my fault, and that they do not, normally, schedule a c-section until 39 weeks, but part of me still feels guilty.

When Kaila contacted me, my heart broke. I emailed her back:

Kaila,

Thank you so much for sharing your story with me and I am so sorry about your loss.

I want you to know that I hear you. I really hear you.

I talk quite a bit about how these small numbers represent real women and real babies and it doesn’t matter how small the risk is, if it happens to you, if you are that number, it’s devastating.

The difficulty is that there are serious risks both ways. With VBAC, we have uterine rupture. With repeat cesareans, we have accreta.

Accreta results in more maternal deaths, more maternal complications and comparable infant deaths and complications to uterine rupture. Accreta requires a more sophisticated response of which many hospitals are unable to offer which results in more deaths and complications. Many women are never told about the risks of accreta which prohibits them from making an informed decision. [View my sources and read more about accreta here.]

I discuss uterine rupture and accreta extensively in my workshops including how often it happens, variables that can impact the rate, and outcomes for mother and baby because there is so much confusion about where the risk lies and what could happen.

The other difficulty is that no one can predict how an individual birth will play out. Will you be the one to have a uterine rupture? An accreta? And in either of these situations, will you be the one to lose your baby? Or will you have a safe VBAC or repeat cesarean with a healthy mom and baby? There are no guarantees in life and no crystal balls.

Some women who lose their babies to uterine rupture say, “Don’t plan VBACs.”

Some women who lose their babies to accreta say, “I wish I had access to VBAC.”

So the question is, if there are serious complications either way, who should make the decision on how to birth?

It always comes down to the mother.

Given the small chance of a bad outcome, women should have the option to decide what set of risks and benefits are tolerable to them. They should not be forced into cesareans or mislead into VBACs. This needs to be their decision based on information. Part of the reason why I started VBAC Facts is that I, as a consumer, wanted more information and it wasn’t easy for me to find.

To bring it full circle, I hear you.

Have you had the opportunity to connect with other loss moms? I have compiled a resource page here.

I know it may ring hollow, but you are not to blame. Sometimes things happen that we cannot predict and that are outside of our control and I’m so very sorry you were the statistic.

I’ll keep you in my heart Kaila. <3

Warmly,

 

Jen

Kaila replied:

I will be honest with you, my doctor did not mention accreta once. Wow that is scary too. 🙁 I don’t wish that or a rupture on anyone. Thank you so much for responding to me. And thank you for advising women on what to do after a C-section. If you ever want to use my story, please let me know. I would be happy to share it for statistic purposes. Thanks so much! 🙂

So I’m sharing Kaila’s story today. As I said in my email to her, I talk about the risks of uterine rupture and accreta in my workshops because they are both real risks on either side of the equation. Sadly, a small number of people will experience this reality, and they deserve our support and compassion.

I do hope you will support Kaila’s Cuddle Cots fundraiser. Even just $10 will get her closer to her goal. Donate here. Connect with her Facebook page here.

Learn more about Infant Loss Awareness here.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Above: “I donated my wedding dress to be made into gowns for deceased infants to be buried in. I had pictures done in my dress before I donated it. This is one of my favorites.” – Kaila Flory

Kaila Flory lost her baby to a uterine rupture eight months ago. She recently reached out to me and gave me permission to share her story and pictures of her son Beau.  She is currently raising money to purchase Cuddle Cots in Beau’s memory. Cuddle Cots are refrigerated bassinets that enable loss parents to spend more time with their child. While t-shirt sales end on April 22, 2016 at midnight EST, you can donate anytime. Even just $10 will get her closer to her goal. Buy a t-shirt and/or donate here.  Connect with her Facebook page here

Women who have had uterine ruptures and lost their babies have endured some of our greatest fears. But they are part of our community as well. When the VBAC Facts Community, a Facebook group, was open to the public, we welcomed and embraced the parents who joined us after their loss. Often they felt like they were no longer part of the birth community. They didn’t know where they fit in. They felt isolated and yet they wanted to share their story. We had many loss moms as members and many parents who were planning VBACs wanted to hear their stories.

What follows is Kaila’s story.

Kaila’s Flory’s first son was born by cesarean after being induced for intrauterine growth restriction. When she was 38 weeks and a few days pregnant with her second son, 26-year-old Kaila started having cramps around 1 a.m. “Luckily I had stayed with my dad, so I was not alone with my 3 year old. My husband was at Basic Training. Then a contraction came. Ok, I thought, this is real. It’s time. Then another came. It had only been like a minute or 2. Then severe pain came over my abdomen, and my face and limbs went numb.”

Her father called the paramedics and she was rushed to the hospital, where a STAT c-section was ordered. She nearly bled to death.

Beau-&-Kaila

“This is the only photo I have of myself holding him. I requested people to not take my photo, but I am so glad my best friend took this with her phone. THIS is what raw, real pain looks like. This is why I want people to have Infant Loss Awareness.”

She says:

While I wholeheartedly believe that women should be given the option for VBACs, I also believe women need to consider their child’s health as the most important in this situation. I would have loved to have 3 weeks of pain just to have my son in my arms. I know it is not my fault, and that they do not, normally, schedule a c-section until 39 weeks, but part of me still feels guilty.

When Kaila contacted me, my heart broke. I emailed her back:

Kaila,

Thank you so much for sharing your story with me and I am so sorry about your loss.

I want you to know that I hear you. I really hear you.

I talk quite a bit about how these small numbers represent real women and real babies and it doesn’t matter how small the risk is, if it happens to you, if you are that number, it’s devastating.

The difficulty is that there are serious risks both ways. With VBAC, we have uterine rupture. With repeat cesareans, we have accreta.

Accreta results in more maternal deaths, more maternal complications and comparable infant deaths and complications to uterine rupture. Accreta requires a more sophisticated response of which many hospitals are unable to offer which results in more deaths and complications. Many women are never told about the risks of accreta which prohibits them from making an informed decision. [View my sources and read more about accreta here.]

I discuss uterine rupture and accreta extensively in my workshops including how often it happens, variables that can impact the rate, and outcomes for mother and baby because there is so much confusion about where the risk lies and what could happen.

The other difficulty is that no can predict how an individual birth will play out. Will you be the one to have a uterine rupture? An accreta? And in either of these situations, will you be the one to lose your baby? Or will you have a safe VBAC or repeat cesarean with a healthy mom and baby? There are no guarantees in life and no crystal balls.

Some women who lose their babies to uterine rupture say, “Don’t plan VBACs.”

Some women who lose their babies to accreta say, “I wish I had access to VBAC.”

So the question is, if there are serious complications either way, who should make the decision on how to birth?

It always comes down to the mother.

Given the small chance of a bad outcome, women should have the option to decide what set of risks and benefits are tolerable to them. They should not be forced into cesareans or mislead into VBACs. This needs to be their decision based on information. Part of the reason why I started VBAC Facts is that I, as a consumer, wanted more information and it wasn’t easy for me to find.

To bring it full circle, I hear you.

Have you had the opportunity to connect with other loss moms? I have compiled a resource page here.

I know it may ring hollow, but you are not to blame. Sometimes things happen that we cannot predict and that are outside of our control and I’m so very sorry you were the statistic.

I’ll keep you in my heart Kaila. <3

Warmly,

Jen

Kaila replied:

I will be honest with you, my doctor did not mention accreta once. Wow that is scary too. 🙁 I don’t wish that or a rupture on anyone. Thank you so much for responding to me. And thank you for advising women on what to do after a C-section. If you ever want to use my story, please let me know. I would be happy to share it for statistic purposes. Thanks so much! 🙂

So I’m sharing Kaila’s story today. As I said in my email to her, I talk about the risks of uterine rupture and accreta in my workshops because they are both real risks on either side of the equation. Sadly, a small number of people will experience this reality, and they deserve our support and compassion.

I do hope you will support Kaila’s Cuddle Cots fundraiser. Even just $10 will get her closer to her goal. Donate here. Connect with her Facebook page here.

Learn more about Infant Loss Awareness here.

What do you think? Leave a comment.

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction. DOWNLOAD NOW

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Shoulder pain is a symptom of uterine rupture

Shoulder pain is a symptom of uterine rupture

I’ve written before about the symptoms of uterine rupture as well as how having an epidural does not interfere with the diagnosis of uterine rupture.

The focus of this Quick Fact is how shoulder pain can be a symptom of uterine rupture.

How can an uterine rupture cause shoulder pain?

Image Source: http://wesleytodd.blogspot.com/2013/10/ablation-for-recurring-af-i.html

Image Source: http://wesleytodd.blogspot.com/2013/10/ablation-for-recurring-af-i.html

Internal bleeding from uterine rupture can cause referred pain through the phrenic nerve which can present in the shoulder.

Shoulder pain is sometimes not included in lists of uterine rupture symptoms, but I have seen it cited multiple places (see below) and have had conversations with OBs, nurses, and anesthesiologists who have experienced uterine ruptures with shoulder pain.

I’m also aware of two cases where the uterine rupture diagnosis was delayed because staff was not familiar with the incidence of referred pain.

Anyone who works with birthing women should be aware of the symptoms of uterine rupture including referred pain.

Please note that not every uterine rupture causes shoulder pain and not all shoulder pain is a symptom of uterine rupture.

Where can you learn more?

I discuss uterine rupture – factors, symptoms, rates, and outcomes – at great lengths in my online workshop, “The Truth About VBAC: History, Politics, & Stats

The following quotes addressing shoulder pain & uterine rupture are from case studies and textbooks. Want more? Google uterine rupture referred pain or uterine rupture shoulder pain.

“APH [brisk antepartum haemorrhage], as in this case, often indicates uterine rupture and may occur in association with shoulder tip pain due to haemoperitoneum.” (Navaratnam, 2011)

“Management of uterine rupture depends on prompt detection and diagnosis. The classic signs (sudden tearing uterine pain, vaginal haemorrhage, cessation of uterine contractions, regression of the fetus) have been shown to be unreliable and frequently absent but any of the following should alert suspicion… Chest or shoulder tip pain and sudden shortness of breath.” (Payne, 2015)

“Signs and symptoms of uterine rupture may include… referred pain in the shoulder (with epidural anesthesia)” (Murry, 2007 p.283)

“Jaw, neck, or shoulder pain can be referred pain from a uterine rupture.” (Murry, 2007, p.76)

“Shoulder pain (Kehr’s sign) is a valuable sign of intraperitoneal blood in subdiaphragmatic region. Even a small amount of blood can cause this symptom, but it is important to realize that it may be 24 h or longer after the bleeding has occurred before blood will track up under the diaphragm, and some cases of acute massive intraperitoneal bleeding may not initially have shoulder pain.” (Augustin, 2014, p. 512)

“Shoulder tip pain may be experienced if significant haemoperitoneum is present, due to irritation of the diaphragm (i.e. referred pain through phrenic nerve).” (Baker, 2015, p.373)

 

Resources Cited

Augustin, G. (2014). Acute abdomen during pregnancy. Switzerland: Springer International Publishing. Retrieved from https://books.google.com/books?id=mq8pBAAAQBAJ

Baker, P. N., McEwan, A. S., Arulkumaran, S., Datta, S. T., Mahmood, T. A., Reid, F., . . . Aiken, C. (2015). Obstetrics: Prepare for the MRCOG: Key articles from the Obstetrics, Gynaecology & Reproductive Medicine journal. Elsevier Ltd. Retrieved from https://books.google.com/books?id=DcqqCgAAQBAJ

Murray, M. (2007). Antepartal and intrapartal fetal monitor. New York, NY: Springer Publishing Company, LLC. Retrieved from https://books.google.com/books?id=_4jYJUGG56cC

Murray, M., & Huelsmann, G. (2008). Labor and delivery nursing: Guide to evidence-based practice. New York, NY: Springer Publishing Company. Retrieved from https://books.google.com/books?id=q22jEEZo7rwC

Navaratnam, K., Ulaganathan, P., Akhtar, M. A., Sharma, S. D., & Davies, M. G. (2011). Posterior uterine rupture causing fetal expulsion into the abdominal cavity: A rare case of neonatal survival. Case Reports in Obstetrics and Gynecology, 2011. Retrieved from http://www.hindawi.com/journals/criog/2011/426127/

Payne, J. (Ed.). (2015, Mar 17). Uterine rupture. Retrieved from Patient: http://patient.info/doctor/Uterine-Rupture

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Myth: 50% of uterine ruptures occur before labor

Myth: 50% of uterine ruptures occur before labor

Becky recently ask this question:

I read somewhere that the risk of uterine rupture is actually higher during pregnancy than during birth. Does anyone have a source for this?

Becky,

I had heard the same thing many times. However, no one who shared this stat with me could ever cite a study substantiating it. I looked and looked on and off for years and never found it.

Instead, I found “Uterine rupture in the Netherlands: a nationwide population-based cohort study” (Zwart, 2009), “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” Zwart differentiated between uterine rupture and dehiscence and included 97% of births in The Netherlands between August 1, 2004 and August 1, 2006. All told, Zwart studied 358,874 total deliveries, 25,989 of which were TOLACs.

I have referenced Zwart before when comparing scarred vs. unscarred rupture rates and scarred vs. induced, unscarred rupture rates. Zwart also included data on pre-labor rupture which I will share with you as well.

Scar rupture before labor

Zwart reported that 9% (1 in 11) of scar ruptures (women with prior cesareans) happened before the onset of labor. When we take 9% of the overall scar rupture rate of 0.64% (1 in 156)*, we get a 0.0576% (1 in 1736) risk of a scar rupture before labor.

Unscarred rupture before labor

Zwart (2009) found 16% (1 in 6.25) of ruptures in women without prior cesareans (unscarred ruptures) occurred before labor and an overall unscarred rupture rate of 0.007% (1 in 14,286)*. When we multiply these two numbers, we get a 0.00112% (1 in 89,286) risk of uterine rupture in an unscarred uteri before labor.

Here is a table comparing the numbers:

Overall UR Rate % of URs that Occur Pre-Labor Pre-Labor UR Rate
Scarred Uteri 0.64% 9% 0.0576%
Unscarred Uteri 0.007% 16% 0.00112%

The war of the studies

Remember, all these stats are based on one study. Other studies might find different rates. However, I think Zwart would have the most accurate rates to date as it is “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country.” This is an important factor because uterine rupture in an unscarred woman is an extremely rare event. We need tens of thousands of women in order to get an accurate number. The fact that Zwart includes over 300,000 unscarred women is huge.

Take home message: The risk of uterine rupture before labor is extremely rare especially for unscarred women.

* This statistic includes non-induced/ augmented, induced, and augmented labors.

Jen

Resources Cited

Zwart, J. J., Richters, J. M., Ory, F., de Vries, J., Bloemenkamp, K., & van Roosmalen, J. (2009, July). Uterine rupture in the Netherlands: a nationwide population-based cohort study. BJOG: An International Journal of Obstetrics and Gynaecology, 116(8), pp. 1069-1080. Retrieved January 15, 2012, from http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02136.x/full

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

False comparison: Fatal car accidents and VBAC

False comparison: Fatal car accidents and VBAC

RETRACTION/ CORRECTION: I originally posted this article challenging the thought that you are more likely to die in a fatal car accident than during a VBAC.  I tried to crunch the numbers in the way that I felt most accurate.  However, it has been bugging me ever since because there is no accurate way to compare these two events and I should have emphasized that more. We can accurately and fairly compare the risks of VBAC to the risks of a repeat cesarean or the risks of a first time time mom.  However, it is a misleading to compare the risks of birth to non-birth events because they are to different.  While I did discuss this at great length at the end of this article, the title I originally chose (Myth: Mom more likely to die in car accident than VBAC) just continued to feed this false comparison.  I have since updated the article and title.  I apologize for any confusion I caused.

_____________________

On fatal car accident statistics: There are many, many variables that factor into an individual’s risk of dying in a car accident.  The most accurate way to calculate your risk is by miles driven.  To learn more, please refer to the National Motorists Association’s document “Understanding Highway Crash Data.” I use the figures below in order to get an average rate for the purpose of discussion.

On terminology: Read why I use the term TOLAC.

_______________________________

Prepare yourself for yet another installation to the Birth Myth series.  I’ve heard this sentiment many times over the years and I’m sure you have too.   The well-meaning people who share this “statistic” simply desire to give moms seeking information on VBAC some encouragement:

If your husband is worried about you dying during a VBAC, tell him you are four times more likely to die in a car accident on your way home from work today.  Sorry if that sounds morbid, but the odds of the mother dying in a VBAC are truly minuscule.

Another article (filled with inaccurate statements, contradictions, and oodles of statistics without sources) recently making the rounds on Facebook says one of the risks of hospital birth is the 1:10,000 risk of a fatal car accident on the way to the hospital.

While these statements are very comforting, as birth myths tend to be, they are false comparisons.  We can accurately and fairly compare the risks of a TOLAC to the risks of a repeat cesarean or the risks of a first time time.  However, it is a misleading to compare the risks of birth to non-birth events.

Comparing unlike risks

Many birth advocates try to weigh the event of uterine rupture against other life events in an attempt to give context, but this is a misleading and inaccurate comparison.  Andrew Pleasant in his article entitled, Communicating statistics and risk, explains:

Try not to compare unlike risks.  For instance, the all-too-often-used comparison ‘you’re more likely to be hit by a bus / have a road accident than to…’ will generally fail to inform people about the risks they are facing because the situations being compared are so different.  When people assess risks and make decisions, they usually consider how much control they have over the risk.  Driving is a voluntary risk that people feel (correctly or not) that they can control.  This is distinctly different from an invisible contamination of a food product or being bitten by a malaria-carrying mosquito.

Comparing the risk of a non-communicable disease, for example diabetes or heart disease, to a communicable disease like HIV/AIDS or leprosy, is similarly inappropriate.  The mechanisms of the diseases are different, and the varying social and cultural views of each makes the comparison a risky communication strategy.

Take away message: Compare different risks sparingly and with great caution because you cannot control how your audiences will interpret your use of metaphor.

Comparing lifetime/annual risk to your risk of something happening over a day (or two)

Your annual or lifetime risk of something happening will often be higher than your risk of a birth related complication.  But this is because the annual risk of something measures your risk for 365 days.  The lifetime risk of something is often based on 80 years.  You are likely to be in active labor for one day, maybe two.  To compare the risk of something that happens over 1-2 days to the aggregate risk of something that could happen any day over 365 days or 80 years is unfair and confusing.

Look at something like your lifetime risk of breast cancer which is often quoted as 1 in 8.  So one could easily say, “Hey, I have a greater risk of breast cancer over my lifetime than I do have a uterine rupture!”  But, let’s look at this a bit more:

Again, I refer to Andrew Pleasant’s article, Communicating statistics and risk:

An oft-reported estimate is the lifetime breast cancer rate among women. This rate varies around the world from roughly three per cent to over 14 per cent.

In the United States, 12.7 per cent of women will develop breast cancer at some point in their lives. This statistic is often reported as, “one in eight women will get breast cancer”. But many readers will not understand their actual risk from this. For example, over 80 per cent of American women mistakenly believe that one in eight women will be diagnosed with breast cancer each year.

Using the statistic ‘one in eight’ makes a strong headline but can dramatically misrepresent individual breast cancer risk.

Throughout her life, a woman’s actual risk of breast cancer varies for many reasons, and is rarely ever actually one in eight. For instance, in the United States 0.43 per cent of women aged 30–39 (1 in 233) are diagnosed with breast cancer. In women aged 60–69, the rate is 3.65 per cent (1 in 27).

Journalists may report only the aggregate lifetime risk of one in eight because they are short of space. But such reporting incorrectly assumes that readers are uninterested in, or can’t comprehend, the underlying statistics. It is critically important to find a way, through words or graphics, to report as complete a picture as possible.

Take away message: Be extra careful to ensure your readers understand that a general population estimate of risk, exposure or probability may not accurately describe individual situations. Also, provide the important information that explains variation in individual risk. This might include age, diet, literacy level, location, education level, income, race and ethnicity, and a host of other genetic and lifestyle factors.

To compare events that are so different like the risk of a fatal car accident and the risk of TOL maternal mortality is inaccurate and doesn’t help moms understand their options.  Your risk of a car accident depends on how much you drive, when you drive, if you are distracted or on medication, etc, etc, etc.  The variables that impact your risk of dying during a  TOLAC are very different.  However, one way these two events are similar:  Sometimes we can make all the “right” or “wrong” decisions and the element of luck will sway us towards a good or bad outcome.

The problems with birth myths and false comparisons

False comparisons and birth myths like this are shared with the best of intentions.  So often the risks of VBAC are exaggerated for reasons having nothing to do with the health of baby and mom.  Birth advocates share these myths (which they believe to be true) as a way of boosting the morale of moms seeking VBAC as these moms are constantly faced with a barrage of unsupportive comments from family, friends, and even care providers.

The problem is, women make plans to have (home) VBAC/VBAMC based on these myths.  They make these plans because birth myths make the risk of VBAC, uterine rupture, infant death, and maternal death look practically non-existent.  That is dangerous.

Perpetuating these myths impedes a mom’s ability to provide true informed consent.  If a mom thinks her risk of uterine rupture is similar to a unscarred mom or a unscarred, induced mom, or less than her risk of getting struck by lighting or bitten by a shark, she does not have accurate picture of the risk.  And if she doesn’t understand the risks and benefits of her options, she is unable to give informed consent or make an informed decision.

Birth advocates get all up in arms about the mom who plans an elective, primary cesarean section without “doing her research.”  Or the mom who consents to an induction at 38 weeks because her OB “said it was for the best.”  Or when an OB coerces a mom into a repeat cesarean by saying the risk of uterine rupture is 15%.  Shouldn’t we be just as frustrated when moms plan (home) VBACs based on misrepresentations of the truth?  Shouldn’t we hold ourselves to the same standard that we expect from others?

The second problem with perpetuating these false comparisons and myths is that once women learn the true risks, they seem gigantic in comparison to the minuscule risk they had once accepted.  Now VBAC seems excessively risky and some loose confidence in their birth plans.  Birth advocates do not support moms by knowingly perpetuating these myths.  The reality is, the risks of VBAC are low.  We don’t need to exaggerate or minimize the benefits or risks of VBAC.  If we just provided women with accurate information from the get go, they would be able to make a true, informed decision.

The third problem is that we really look dumb when we say stuff like this.  If we want to be taken seriously, we really need to double check what we pass on.  I encourage you to ask for a source when someone says something that sounds to good to be true or just plain fishy.  (And hold me to the same standard!)  I often ask people for a source for their assertions… with varying results.

Sometimes people have a credible source available and share it with me.  I learn more and it’s all good.  Other times, people get angry.  They think I’m challenging them or trying to argue with them.  But the truth is, I’m just trying to learn. What I have found is, when people get angry, it’s sometimes because they don’t have a source and they are insulted that I didn’t accept their statement at face value.  They have just accepted what a trusted person told them as the truth and expect me to do the same.

Doesn’t it strike you as odd that some people encourage the continual questioning OBs and the medical system, yet expect you to accept what they say as The Truth no questions asked?   “Question everyone but me.”  Why?  Why is it when we question an OB, that’s a good thing, yet when we hold our birthy friends and colleagues to the same standard, that is being argumentative?  I say, ask for the source.  From everyone.

Take away messages

It is inaccurate and misleading to compare two events that are as different as a fatal car accident and TOL maternal mortality.  Period.

Let’s stop this false comparison and bring us back to what we should be comparing TOLAC/VBAC to: the risks of a repeat cesarean.

When women plan a VBAC based on false information,  their confidence can be shattered when they learn that the risk of uterine rupture and maternal death are much higher than they were lead to believe.

When women plan a VBAC based on false information, they are deprived of their right to informed consent.

While the risk of scar rupture is very different than the risk of a fatal car accident, it is similar to other serious obstetrical emergencies such as placental abruption, cord prolapse, and postpartum hemorrhage.

Guise J-M, Eden K, Emeis C, Denman MA, Marshall N, Fu R, Janik R, Nygren P, Walker M, McDonagh M. Vaginal Birth After Cesarean: New Insights. Evidence Report/Technology Assessment No.191. (Prepared by the Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-2007-10057-I). AHRQ Publication No. 10-E003. Rockville, MD: Agency for Healthcare Research and Quality. March 2010.   http://www.ahrq.gov/downloads/pub/evidence/pdf/vbacup/vbacup.pdf

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For those who are interested in the reasoning and mathematics from the original article:

But, if we were going to compare the unlike risks of a fatal car accident and TOLAC, this is how I would do it: compare the daily risks of the events.

Maternal death and TOL

Per the report presented at the 2010 NIH VBAC conference entitled Vaginal Birth After Cesarean: New Insights (Guise, 2010):

Overall rates of maternal harms were low for both TOL [trial of labor] and ERCD [elective repeat cesarean delivery]. While rare for both TOL and ERCD, maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL . . . The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7/1,000 versus 0.3/1,000 ERCD).

Put another way, there is a 0.0038% (1 in 26,316) risk of maternal death during a trial of labor.  For a mom to die is very rare.

Risk of a fatal car accident

Of the 311,000,000 people living in the US (US Census, 2012), about 40,000 die annually (Beck, 2006) from car accidents in the United States which gives us a annual rate of 0.0129% (1 in 7,752).  (But remember, this is a very rough representation of the risk due to all the factors I previously mentioned.)

Many women look at this number and say, “See, you are more likely to die in a car accident than during a TOL.”

But remember, 0.0129% (1 in 7,752) is the annual rate of Americans dying due to car accidents.

To compare something like your annual risk of a fatal car accident to your risk of dying during a TOL is an unfair and inaccurate comparison.   It would be more accurate (though still a false comparison) to compare your daily risk of a fatal car accident (because most people travel in a car every day) to the risk of maternal death during a TOL because you are not in labor every day for a year.  Let me explain.

Comparing TOL maternal mortality to fatal car accidents

Often this false comparison is expressed as, “You are more likely to have a fatal car accident on the way to the hospital than have a uterine rupture or die during a VBAC.”  But the risk of a fatal car accident on the day you drive to the hospital is not 1 in 7,752.  That is your risk over a year.  We have to estimate your risk on that day you drive to the hospital by dividing 0.0129% by 365 days which equals 0.00003534% or 1 in 2,829,458.

No matter what stat we use from any study, the risk of maternal mortality during a TOL is much greater.  (But remember, this is a false comparison anyways!)

Guise’s data pegs the risk at 0.0038% or 1 in 26,316 which is 107.5 times greater than the risk of a fatal car accident as you drive to the hospital in labor.  This does not mean that the risk of dying during a TOL is so large, but rather our daily risk of a fatal car accident is so small that it’s literally theoretical.  (Read Kim James’ “Understanding obstetrical risk” for more.)

What about the risk of uterine rupture?

Using the 0.47% (1 in 213 TOLs) risk of scar rupture (Guise, 2010), the risk of a fatal car accident is 13,283 times smaller.

Why don’t we spread the risk of rupture/maternal mortality across the entire pregnancy?

After I initially published this article, someone left this great comment on Facebook:

I get this, but I also get why using annual stats of car accidents would be accurate when you are looking at uterine rupture rates themselves and not just during TOL, since a risk of rupture exists throughout pregnancy and not just during labor and mom would be pregnant for approximately 10 months or more.

I wondered about the best way to crunch the numbers because these events are so different and thus so difficult to compare.  In the end, it is a false comparison, but here was my original thinking….

Most Americans are in a car everyday, so they have that risk – no matter how small – every day unless they are not in a car in which case their risk is zero.  The risk is primarily associated with being in a car.

The risk of uterine rupture and maternal mortality is primarily associated with being in labor, so we can’t spread the risk of rupture/maternal mortality across the whole pregnancy because the risk of rupture/maternal mortality is not the same from conception to delivery.

One study examined 97% of births that occurred in the The Netherlands from 1st August 2004 until 1st August 2006 and found that 9% (1 in 11) of scar ruptures happened before the onset of labor. When we take 9% of the overall rate of scar rupture 0.64% (1 in 156) (including non-induced/augmented, induced, and augmented labors), we get a 0.0576% (1 in 1736) risk of pre-labor scar rupture and a 0.5824% (1 in 172) risk of rupture during labor (Zwart 1009). Since the risk of rupture is not the same over the entire pregnancy and labor, we cannot accurately calculate a daily risk of rupture.

In other words, the risk of rupture is rare before labor (0.0576% or 1 in 1736) and then becomes uncommon when labor begins (0.5824% or 1 in 172).  Even though we could go into labor anytime during pregnancy, the risk before we go into labor is so small in comparison to the risk when we actually go into labor.

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Can you feel a uterine rupture with an epidural?

Can you feel a uterine rupture with an epidural?

Some care providers discourage epidurals in VBAC moms fearing that it will mask the symptoms of uterine rupture (namely abdominal pain) and delay diagnosis resulting in a poor outcome for baby and to a lesser extent, mom  Other care providers suggest or even require VBAC moms to have an epidural so that a cesarean can quickly take place if needed.  Which philosophy does the evidence support?

Review of 14 VBAC studies

I recently came across a study entitled “The Role of Epidural Anesthesia in Trial of Labor” (Johnson, 1990) that reviewed 14 VBAC studies.  Johnson found among scarred women who ruptured, a greater percentage of women with epidurals reported abdominal pain than women without epidurals.

  • 5 of 14 (35.7%) patients with an epidural who ruptured had abdominal pain.
  • 4 of 23 (17.4%) patients without an epidural who ruptured had abdominal pain.

Interestingly, only 22% of the women who ruptured in that study reported abdominal pain and Johnson concluded, “Thus abdominal pain is an unreliable sign of complete uterine rupture.”  But is it?  69% of women in Zwart (2009) reported abdominal pain. (I write about Zwart here and here.)

One difference between the studies is Zwart included significantly more scarred moms than Johnson: 26,000 versus 10,976.  The second different is that Zwart also included 332,000 unscarred women representing 93% of the sample population.

Unscarred moms, uterine rupture, and abdominal pain

I’m curious if the reason why Zwart reported such a high level of abdominal pain was because it included so many unscarred moms.  I wonder if unscarred moms are more likely to report pain and if so, why would that be.  Zwart combines the symptoms for scarred and unscarred rupture into one chart.  If they broke that chart out by scarred vs. unscarred rupture symptoms, would we see any major differences? Generally, unscarred rupture does more damage to the uterus and is more likely to result in an infant death (Zwart, 2009), so maybe because there is more damage, women report more abdominal pain?

Most common UR symptom: fetal heart tone abnormalities

I checked out  eMedicine’s article “Uterine Rupture in Pregnancy” and was fascinated to learn that several studies concur with Johnson.  They also found that abdominal pain is reported at a much lower rate than fetal distress/ abnormal fetal heart tones:

…sudden or atypical maternal abdominal pain occurs more rarely than do decelerations or bradycardia. In 9 studies from 1980-2002, abdominal pain occurred in 13-60% of cases of uterine rupture. In a review of 10,967 patients undergoing a TOL, only 22% of complete uterine ruptures presented with abdominal pain and 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring. [This is the Jonhson study.]

Moreover, in a study by Bujold and Gauthier, abdominal pain was the first sign of rupture in only 5% of patients and occurred in women who developed uterine rupture without epidural analgesia but not in women who received an epidural block.  (Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors?. Am J Obstet Gynecol. Feb 2002;186(2):311-4).  Thus, abdominal pain is an unreliable and uncommon sign of uterine rupture. Initial concerns that epidural anesthesia might mask the pain caused by uterine rupture have not been verified and there have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture.

A 2012 study out of the UK (Fitzpatrick, 2012) also reported that 76% of uterine ruptures were accompanied by fetal heart rate abnormalities in comparison to 49% reporting abdominal pain.

ACOG’s stance on epidurals

It’s important to note that ACOG does support the use of epidurals in VBACs:

Epidural analgesia for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC (109, 110). No high quality evidence suggests that epidural analgesia is a causal risk factor for an unsuccessful TOLAC (44, 110, 111). In addition, effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture, particularly because the most common sign of rupture is fetal heart tracing abnormalities (24, 112).

Remember that fetal heart tracing abnormalities were detected in 76% of the ruptures in Johnson ad 67% of the ruptures in Zwart.

I couldn’t find any mention of epidurals masking rupture pain in the Guise 2010 Evidence Report, but found that the Johnson study was excluded from their report because “No full-text paper, opinion or letter with no data.”  Interesting.

Uterine rupture symptoms

A list of uterine rupture symptoms and their frequency per Medscape’s article on uterine rupture.

  • “80% Prolonged deceleration in fetal heart rate or bradycardia
  • 54% Abnormal pattern in fetal heart rate
  • 40% Uterine hyper-stimulation
  • 37% Vaginal bleeding
  • 26% Abdominal pain
  • 4% Loss of intrauterine pressure or cessation of contractions”

A couple notes.  One, abdominal pain is not a consistent or reliable symptom of UR.  Two, there is a level of interpretation that goes into diagnosing abnormal fetal heart tones even among people who have extensive medical training.

Additional symptoms that I have collected from other sources include:

  • Baby’s head moves back up birth canal
  • Bulge in the abdomen or under the pubic bone (where the baby may be coming through the tear in the uterus)
  • Uterus becomes soft
  • Shoulder pain

Risks and benefits of epidurals

As with every option available to you regarding birth, it’s always good to be knowledgeable on the risks and benefits of epidurals so you can make an informed choice.  Three excellent resources are this article by Sarah Buckley MD, the PubMed Health Epidural Fact Sheet and this review of epidural research by the Cochrane Library.

Take home message

The limited information available tells us that epidurals do not mask abdominal pain from uterine rupture.

The most common symptom of uterine rupture is fetal distress diagnosed by fetal heart rate abnormalities.

Epidurals may be used during a trial of labor after cesarean per ACOG.

___

As always, if you can offer further research or perspective on this topic, please leave a comment.  Our knowledge is constantly growing and we can only work with the best information available to us now.  Who knows what future research will tell us?

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.

Myth: VBACs should never be induced

Myth: VBACs should never be induced

Note: When I refer to a spontaneous labor, I mean a non-induced/augmented labor. Also, given that the risk of rupture increases with induction, a hospital is the best location for an induction.

___________________________________________

Many of the comments left at the Forced Cesarean mom story questioned the safety of inducing a VBAC mom. Many people believe that is it excessively dangerous and that VBACs should never been induced or augmented. This is just not the case.

Spontaneous labor is always preferable to induced or augmented labor but there are medical conditions that can necessitate the immediate birth of a baby. It’s nice for those women for whom vaginal birth is still an option to have a choice: gentle induction/ augmentation or repeat cesarean. Of course, reviewing the risks and benefits of available options, including doing nothing, is essential. Some women might be more comfortable scheduling a cesarean whereas others might want to give a gentle Pitocin and/or Foley catheter induction a go.

ACOG’s stance on inducing VBACs

The latest 2010 VBAC Practice Bulletin No. 115 produced by the American Congress of Obstetricians & Gynecologists (ACOG) asserts:

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean]… However, the potential increased risk of uterine rupture associated with any induction, and the potential decreased possibility of achieving VBAC, should be discussed… Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.

Stuart Fischbein MD, a vaginal breech/twins and VBAC supportive Southern California OB, recently shared this on my Facebook page,

According to ACOG, prior low transverse c/section is not a contraindication to induction (other than the use of Misoprostol [Cytotec]) so a Foley balloon or Pitocin may be used safely in these women. The problem arises when a practitioner does not believe in doing inductions on women with prior c/section. Despite the evidence and the ACOG clinical guideline the reality is that many doctors will just not want to deal with it.

“Many doctors will just not want to deal with it” for a variety of reasons including experiencing a recent uterine rupture or lawsuit and pressure from hospital administrators or other OBs in their practice. It’s good to know from the beginning if your care provider is open to a gentle VBAC induction and under what conditions they would recommend induction. (See below for the Mayo Clinic’s reasons for induction.) This is why I suggest asking care providers when you first meet with them: “Under what circumstances would you induce a VBAC?” and “What induction methods do you use?”

Medical reasons for induction

While many women are induced for non-medical reasons, such as being pregnant for 40 weeks and one day, there are many medical conditions where induction is a reasonable option. According to the Mayo Clinic’s article Inducing labor: when to wait, when to induce dated July 23, 2011:

Your health care provider might recommend inducing labor for various reasons, primarily when there’s concern for your health or your baby’s health. For example:

  • You’re approaching two weeks beyond your due date, and labor hasn’t started naturally
  • Your water has broken, but you’re not having contractions
  • There’s an infection in your uterus
  • Your baby has stopped growing at the expected pace
  • There’s not enough amniotic fluid surrounding the baby (oligohydramnios)
  • Your placenta has begun to deteriorate
  • The placenta peels away from the inner wall of the uterus before delivery — either partially or completely (placental abruption)
  • You have a medical condition that might put you or your baby at risk, such as high blood pressure or diabetes

ACOG’s 2009 recommendations on induction lists the following reasons:

  • Abruptio placentae [placental abruption]
  • Chorioamnionitis [infection in your uterus]
  • Fetal demise [baby has passed away]
  • Gestational hypertension
  • Preeclampsia, eclampsia
  • Premature rupture of membranes
  • Postterm pregnancy [after 42 weeks]
  • Maternal medical conditions (eg, diabetes, mellitus, renal [kidney] disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome)
  • Fetal compromise (eg, severe fetal growth restriction, isoimmunization, oligohydramnios)

Big babies & going overdue

ACOG’s latest VBAC Pratice Bulletin No. 115 states that going over 40 weeks or suspecting a “big baby” should not prevent a woman from planning a VBAC. I suggest asking your care provider at your first appointment about what they would recommend doing if you go past 40 weeks, past 42 weeks, or if they believe your baby is large. They may suggest a cesarean, a gentle induction, or they be open to waiting for spontaneous labor. Then you decide how you feel about their answer. If you decide that their answer is not a good fit for you, you can weigh that against the responses of other VBAC supportive care providers in your area.

Uterine rupture rates in induced/augmented labors

There are two primary factors when looking at uterine rupture during an induction: the drug and the dose. Keep in mind that while the risk of rupture generally increases as the dosage increases, two women can respond very differently to the same dose of the same drug. According to JHP Pharmaceuticals, LLC, the manufacturer of Pitocin,

Oxytocin has specific receptors in the myometrium and the receptor concentration increases greatly during pregnancy, reaching a maximum in early labor at term. The response to a given dose of oxytocin is very individualized and depends on the sensitivity of the uterus, which is determined by the oxytocin receptor concentration.

Additionally, they assert that Pitocin should not be used for induction without medical indication:

Elective induction of labor is defined as the initiation of labor in a pregnant individual who has no medical indications for induction. Since the available data are inadequate to evaluate the benefits-to-risks considerations, Pitocin is not indicated for elective induction of labor.

Many women point to the fact that the Pitocin drug insert states, “Except in unusual circumstances, oxytocin should not be administered in the following conditions” and then lists “previous major surgery on the cervix or uterus including cesarean section.” However, a prior cesarean is not listed under contraindications and the drug insert is clear:

The decision [to use Pitocin in a woman with a prior cesarean] can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm.

The elevated risk of rupture due to induction has been documented in several studies. Landon (2004) found that spontaneous labors had a 0.4% rate of rupture. That increased 2.5 times for induced labors (1.0%) and 2.25 times for augmented labors (0.9%).

Landon further broke out rupture rates by type of induction:

  • 1.4% (N = 13) with any prostaglandins (with or without oxytocin)
  • 0% with prostaglandins alone
  • 0.9% (n = 15) with no prostaglandins (includes mechanical dilation with a foley catheter with or without oxytocin), and
  • 1.1% (N = 20) with oxytocin alone.

Overall, they found 0.7% of women experienced an uterine rupture with an additional 0.7% experiencing a dehiscence.

Landon (2004) did a great job in providing rates of rupture per drug, but we don’t know the dose used in the induced/ augmented labors that ruptured versus those that didn’t rupture.

ACOG quotes a couple studies in their 2010 VBAC Practice Bulletin (emphasis mine):

One study of 20,095 women who had undergone prior cesarean delivery (81) found a rate of uterine rupture of 0.52% for spontaneous labor, 0.77% for labor induced without prostaglandins, and 2.24% for prostaglandin induced labor. This study was limited by reliance on the International Classification of Diseases, 9th Revision coding for diagnosis of uterine rupture and the inability to determine whether prostaglandin use itself or the context of its use (eg, unfavorable cervix, need for multiple induction agents) was associated with uterine rupture.

In a multicenter study of 33,699 women undergoing TOLAC, augmentation or induction of labor also was associated with an increased risk of uterine rupture compared with spontaneous labor (0.4 % for spontaneous labor, 0.9% for augmented labor, 1.1% for oxytocin alone, and 1.4% for induction with prostaglandins with or without oxytocin) (4). A secondary analysis of 11,778 women from this study with one prior low transverse cesarean delivery showed an increase in uterine rupture only in women undergoing induction who had no prior vaginal delivery (1.5% versus 0.8%, P=.02). Additionally, uterine rupture was no more likely to occur when labor induction was initiated with an unfavorable cervix than with a favorable cervix (91). Another secondary analysis examined the association between maximum oxytocin dose and the risk of uterine rupture (94). They noted a dose response effect with increasing risk of uterine rupture with higher maximum doses of oxytocin. Because studies have not identified a clear threshold for rupture, an upper limit for oxytocin dosing with TOLAC has not been established.

Induced labor is less likely to result in VBAC than spontaneous labor (44, 47, 92, 99). There is some evidence that this is the case regardless of whether the cervix is favorable or unfavorable, although an unfavorable cervix decreases the chance of success to the greatest extent (91, 100, 101). These factors may affect patient and health care provider decisions as they consider the risks and benefits of TOLAC associated with labor induction.

Given the lack of compelling data suggesting increased risk with mechanical dilation and transcervical catheters, such interventions may be an option for TOLAC candidates with an unfavorable cervix.

The Guise 2010 Evidence Report is another excellent resource that reviewed VBAC research published to date. It talks extensively about uterine rupture in induced births on pages 58 – 69 and concluded (emphasis mine):

The strength of evidence on the risk of uterine rupture with pharmacologic IOL [induction of labor] methods was low due to lack of precision in estimates and inconsistency in findings. The overall risk of rupture with any IOL method at term was 1.5 percent [1 in 67] and 1.0 percent [1 in 100] when any GA [gestational age] is considered. Among women with GA greater than 40 weeks, the rate was highest at 3.2 percent [1 in 31]. Evaluation of the evidence on specific methods of IOL reveal that the lowest rate occurs with oxytocin [Pitocin] at 1.1 percent [1 in 91], then PGE2 [prostaglandin E2] at 2 percent [1 in 50], and the highest rate with misoprostol [Cytotec] at 6 percent [1 in 17]. These findings should be interpreted with caution as there was imprecision and inconsistency in the results among these studies. The risk of uterine rupture with mechanical methods of IOL is understudied. Other harms were inadequately reported to make conclusions. Relative to women with spontaneous labor, there was no increase in risk of rupture among those induced at term. However, the available evidence on women with induced labor after 40 weeks GA indicates an increased risk compared with spontaneous labor (risk difference 1.8 percent; 95 percent CI: 0.1 to 3.5 percent). The NNH [number needed to harm] in this group is 56 (for every 56 women greater than 40 weeks GA with IOL during a TOL [trial of labor], one additional rupture will occur compared with having spontaneous labor).

So the bottom line is: more large, good quality studies that control for induction are needed.

What is too risky?

As ACOG (2010) states in their latest Practice Bulletin:

Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.

I agree and believe that each individual woman has the right to informed consent and, together with her care provider, can make the best decision for her individual situation. I think it’s hard to argue that women seeking VBA2C, home birth, or unassisted birth should have the right to accept the elevated levels of risk that come with those decisions and yet say that the elevated risk that comes with induced VBACs is unacceptable.

Keep in mind that while the risk of rupture is higher in an induced VBAC, the risk is similar to the risk of rupture in a VBA2C (0.9% per Landon 2006). So it’s hard for one to support VBA2C and yet demonize a VBA1C induced for medical indication by saying the risk of rupture is to high.

It is also important to note that 90 out of 91 Pitocin induced TOLACs do not rupture (Landon, 2004 & Guise, 2010). So while the risk is generally higher in induced/ augmented labors, the overall risk is still low and occurs at a rate comparable to other obstetrical emergencies.

Myth: Most ruptures occur in induced/augmented labors

It’s imperative that women seeking VBAC understand that the single factor that increases their risk of uterine rupture the most is their prior cesarean section. And while having your labor induced/augmented does increase your risk of rupture, please do not believe the myth that a spontaneous labor provides complete protection from uterine rupture.

To disprove this myth, I direct you to “the largest prospective report of uterine rupture in women without a previous cesarean in a Western country” which found that most ruptures occur in spontaneous labors (Zwart, 2009). Zwart differentiated between uterine rupture and dehiscence and found (emphasis mine):

of the 208 scarred and unscarred uterine ruptures, 130 (62.5%) occurred during spontaneous labor reflecting 72% of scarred ruptures and 56% of unscarred ruptures.

It is interesting to note that 16% of unscarred ruptures (representing 4 unscarred women) and 9% of scarred ruptures (representing 16 scarred women) happened before the onset of labor (Zwart, 2009).

What I would do

If there was a medical reason for my baby to born (as detailed by the Mayo Clinic above), and it was the difference between a VBAC and a repeat cesarean, and I had a favorable Bishop’s score (download the app), I would consent to a foley catheter and/or low-dose Pitocin induction (not Cytotec or Cervidil).

If I was induced or augmented with Pitocin, I would be comfortable with continuous external fetal monitoring. Some hospitals do offer telemetry which is wireless monitoring giving you more freedom of movement. I’ve even seen telemetry in tube tops (naturally I can’t find a link to it now, if you have a link, can you leave a comment?) and units that can be worn in birth tubs. It’s good to call the hospital beforehand to determine what kind of telemetry monitoring units they offer and to confirm that it’s not lost in a closet.

Final thoughts

There is no doubt that Pitocin is overused in America and often results in unnecessary emergency cesareans. However, it’s important not to cloud the two issues: medically unnecessary inductions and inductions with medical indication. There are situations where induction/ augmentation are reasonable and can give the mom one last option before having a cesarean. Thankfully, a low-dose Pitocin and/or foley catheter induction “remains an option” in women planning a VBAC according to ACOG. I think that is a good thing.

Further reading

What do you think? Leave a comment.

Jen Kamel

Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.

Learn more >

Free Report Reveals...

Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.

VBAC Facts does not provide any medical advice and the information provided should not be so construed or used. Nothing provided by VBAC Facts is intended to replace the services of a qualified physician or midwife or to be a substitute for medical advice of a qualified physician or midwife. You should not rely on anything provided by VBAC Facts and you should consult a qualified health care professional in all matters relating to your health.