Update on uterine rupture

I love my well educated, experienced commenters. There was a good, lively discussion about catastrophic uterine rupture risk on a recent post about vaginal birth after cesarean (VBAC) attempts. Well, I found a statistic!

According to Lyerly et al:

Although rates of delivery-related perinatal death are indistinguishable between VBAC and primary vaginal delivery, there is a genuine differential in the rate of uterine rupture–related hypoxicischemic encephalopathy. Such perinatal morbidity is indeed devastating. It is also extremely rare. In a recent large prospective study, the probability of this outcome was 0.00046 in infants whose mothers underwent a VBAC trial at term compared with no cases in infants whose mothers underwent repeat cesarean delivery.

Two important points here. Uterine rupture that actually causes perinatal morality has a probability of 0.00046. That is, by all measures, extremely, extremely rare. Also, all causes of perinatal mortality for VBAC were identical to perinatal mortality risk for a first time vaginal delivery.

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14 Comments

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14 responses to “Update on uterine rupture

  1. cileag

    Wow, just wow. That’s pretty astonishing.

  2. Anne

    So section them all right? Why let primips birth, when the baby could die?!?!? @@

    Hopefully, you caught the sarcasm :-)

    Thanks for posting this…I like a little perspective.

    ~A

  3. Thanks for finding this. I think it is SO important that moms are informed of the (small) risks of VBAC and they THEY should choose what they want!

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  5. Looks like that references the Landon 2004 study which found the rate
    of bad infant outcomes as 0.05% which is 0.00046 expressed as a
    percentage (0.046%) and rounded up.

    Sometimes people get confused and think the 0.00046 number is a
    percentage, so they see that number and think the risk is really super
    small rather than just super small! :)

  6. HappenedtoMe

    Statistic do not tell the whole story for uterine rupture. The statistics you are quoting are best case senarios, which may not always be the case. I was a prime candidate for VBAC, or so I was told. What was not listed in the medical records with my first c-section was that an inverted-T insision was performed. This incision dramatically increased my chance of rupturing. Due to this lack of information, I lost my beautiful daughter during my VBAC attempt due to a unterine rupture.

    Statistics are only statistics until you become one of them. While I don’t approve of scare tactics, I do think it is important for women to assess their own comfort level with risk and unknown factors. Unfortunately, I know of several other women who also had un-notated T-incisions and ruptured during a VBAC.

    In my option, reducing the need for VBACs by lowering the first-time c-section rate is essential.

    • MomTFH

      Yes, lowering primary cesareans is essential for reducing the need for VBACs.

      I think the need for a low vertical incision to be a good candidate for a VBAC attempt is very clear in the literature and in practice, when VBAC attempts are allowed at all. Anyone attempting or attending a VBAC should check the operative reports to see what the incision was in the uterus, because the incision on the skin may not be the same.

      Edited to add: I must have read quickly and missed this happened to you. I am so sorry. As rare as a complication may be, if you are the one it happens to, it is no less devastating.

    • First, let me say how sorry I am that you lost your precious daughter. *hugs*

      From the Landon Study (the only study to include Inverted T VBACs):
      Low Transverse – 0.7%
      Low Vertical – 2.0%
      Classical, Inverted T or J – 1.9%
      Unknown – 0.5%

      Your risk of rupture was not dramatically higher than someone with a low transverse, only slightly higher. Can I ask if your VBAC labor was induced? That can significantly raise your risk of rupture. How did you find out that your first cesarean was an Inverted T?

      I had an induced vag, a low transverse c/s, then an inverted T c/s (the vertical portion extended into the fundus), then a perfect water birth VBAC in a birth center. I know of 3 other women with Inverted T scars who successfully VBAC’d since February. I also know of another woman who ruptured but did not lose her baby. I know rupture can happen, but I also know that successful VBAC’s can happen too! I am planning another VBAC for next spring.

      I agree 100% that primary sections need to be reduced. Especially since 95% of the OBs where I live don’t *do* VBACs.

      I am amazed that there are women who’ve had Inverted T cesareans that were not noted properly on their surgical report. Did you all go to the same OB per chance? OBs love to have ammo not to let a woman VBAC, Inverted T scars are one of their favorites. :-(

      Again, I’m so sorry that you lost your daughter. I cannot imagine the pain.

  7. MomTFH- Thanks for putting this up. It is an extremely small number and, therefore, highly unlikely. Before our HBA2C last year, I was more astonished with all of the infant issues and risks associated with elective repeat c-section (especially after surgical birth). I wanted to avoid all of THOSE risks, too. It angered me that my hospital was completely taking my choice away. We ended up giving birth out-of-hospital when left with no voice. When I went into labor, we had to drive across TWO state lines in a snowstorm to give birth. It was absolutely perfect and my wishes and beliefs were fully respected by our CNM.

    Jen@VBACFacts.com – Thanks for clarifying. I was actually thinking *wait, I thought it was .05%* and, duh, it IS! LOL 0.05% is virtually the same as .00046 which, if I’m not mistaken, is 1 out of 2,000 births.

    HappenedtoMe- I just want to say how very sorry I am to hear of your loss. I’ve had IRL friends who lost their babies at term and there really are no words to fully convey my sadness and sympathy. It’s just heartbreaking. And I agree…lowering first-time c-section rates is essential.

    I wanted to point out that the Landon statistics are actually not all best case scenarios. One thing that is a little frustrating about this study is that pitocin is used throughout these cases and yet it’s not considered as a statistical variable. It’s possible that most of these VBACs were pitocin induced or augmented since they took place in the hospital. Since we know this and other synthetic forms of oxytocin stresses out the uterus and automatically creates a higher percentage of rupture, this tiny .00046 risk is likely even lower. Until the study is completely re-done withOUT pitocin, we won’t know what the real risk is. Further, this study included moms with FOUR previous c-sections. The statistic lumps everyone with 1, 2, 3, or 4 previous c-sections together. Therefore, when a mom takes the Landon study into her OB, even if she’s had 4 c-sections, the .00046 statistic applies to her, too. It’s really quite astounding.

    Thanks, again, MomTFH! When we’re making these decisions, statistics are important to many of us as we sometimes use history to defend our choices. These studies show that a tiny percentage of us will have negative outcomes when selecting VBAC. When comparing these risks to many of the other choices we make in life every day, they are quite small. Scare tactics are completely unnecessary. We make the best choices with what we know and the rest is simply out of our hands.

  8. Anna

    I found this blog during a search on what happened to me.
    I had given birth to two children via Csection….then I tried to have a VBAC with my third child. The senior dr of the practice was against the idea, but the others wanted me to try it.

    The end result was that I had a catastrophic uterine rupture, and my daughter and I almost died. They had to do an emergency hysterectomy as well as emergency csection.

    Thank God we were okay….my daughter is 11 years old now.

    • MomTFH

      I am glad you are both fine.

      Just like in any situation, catastrophic complications can occur. Still, evidence based guidelines written by the American College of Ob/Gyn, based on research on large groups of women (not one anecdotal story) show that in an appropriate case (no induction, no classical incision, etc) a trial of labor is safer than a repeat cesarean for the mother and fetus, and rarely ends in a catastrophic rupture.

      I am sorry that happened to you. But, not only is VBAC safer in most cases, but the guidelines say to offer VBAC to all eligible women.

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  10. nicky

    i discovered this website whilst looking up statistics for a ruptured uterus happening for a third time.I lost my son and daughter in 2006 and 2007 due to this condition and i wasnt even in labour,it just happened! i am desperate for another baby and couldnt find another story of somebody else who wasnt in labour.please help i need all the info i can get.xxxx

    • MomTFH

      I am sorry this happened to you. Here is some information about uterine rupture, and if you scroll down, you will see a section labelled “Rupture of the unscarred uterus before labor versus during labor”. The study they mentioned had 14% of uterine ruptures happening before labor.

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