October 3, 2007

New Study Reports on Uterine Rupture Risks After Cesarean

Given that some hospitals outright refuse to allow women to attempt a VBAC, and the American College of Obstetricians and Gynecologists actually felt it was necessary to dissuade its member OB/GYNs in a policy statement from seeking court orders to force c-section when women refuse, you might assume that the risk of uterine rupture or other complications is extremely high following a previous cesarean. However, new evidence suggests that the actual risk may be lower than is commonly believed.

The October issue of the journal “Obstetrics & Gynecology” includes findings from a large study that followed 39,117 women at multiple medical centers who had a singleton pregnancy and a prior cesarean section. The details of the women’s term vaginal births and c-sections were recorded, along with information on any adverse events. The study was observational, meaning that the researchers didn’t randomize women to one type of birth or another, but simply recorded what happened.

Researchers separated these women into five groups to assess the outcomes, consisting of those undergoing: 1) a trial of labor (with no plans for c-section); 2) elective repeat c-section with no labor; 3) elective repeat c-section after the onset of labor; 4) non-elective (medically indicated) repeat c-section with no labor; 5) non-elective c-section after onset of labor.

A few of the findings:

-Of the trials of labor, 73.3 percent were successful (11,226 successful vaginal births after cesarean of the 15,323 attempted).

-Six maternal deaths occurred, but none were associated with uterine rupture. Five of these occurred in the elective repeat cesarean group, and one was after trial of labor (resulting from hemorrhage).

-While uterine rupture was more common in those with trial of labor (0.74 percent) than in those with elective c-section (0-0.15 percent), rates of overall complications were similar between the groups (5.3 percent for the trial of labor group, compared with 3.4-6.4 percent in the elective c-section groups).

-The rate of uterine rupture was highest in those undergoing a trial of labor, but was <1 percent.

-Among women having repeat cesareans, rates of uterine rupture were highest in those with a medical indication for repeat cesarean and some labor (0.28 percent), and next-highest in those with elective c-section and some labor (0.15 percent).

-The overall risk of serious adverse perinatal outcome was 0.27 percent. The trial of labor group had the highest rate of antepartum stillbirth (0.22 percent) and hypoxic ischemic encephalopathy (0.08 percent) of the five groups, but had lower or similar rates of intrapartum stillbirth and neonatal death compared with some of the other groups.

This study has certain limitations, such as the focus on short-term outcomes - the authors are not able to comment on less immediate postpartum outcomes such as infection, pain, or hospital readmission, or on long-term reproductive health. Previous research suggests that women who have cesarean births are more likely than woman who have vaginal births to experience these less immediate problems. However, it may be a good starting point for talking realistically about the likelihood of complications when women attempt a vaginal birth after cesarean, rather than continuing to rely solely on the "conventional wisdom."

For additional information on cesarean section, see this summary from our Health Resource Center.


10 Responses to “New Study Reports on Uterine Rupture Risks After Cesarean”

  1. Hilary Says:

    Yeah, I have found that a few of ACOG’s position statements are not based on the available evidence, IMO.

    In this study, as in others, I find it ironic that the “success rate” of these women attempting a vaginal birth after cesarean is actually higher than the vaginal birth success rate of ALL women attempting vaginal birth at most of the hospitals in South Florida.

  2. Rachel Says:

    Hilary, thanks for your comment.

    Also, another limitations note – the study did not report the rate of induction, which may have made a difference in the outcomes.

  3. Cyndi Gross Says:

    Many people believe that the reason VBAC’s are hard to get is because of increased uterine rupture, but that is not the reason. Many of the doctors that I have worked with over the years told me that it is partly because of litigation but mostly because insurance companies insist that a doctor be on site for all VBAC’s. They were discouraging VBAC’s because they didn’t want to have to stay at the hospital for an entire labor! My point back to them was, shouldn’t a doctor always be on site and available for any emergency?

    Many of the docs who would do a VBAC would induce them to get it done faster, upping the chances of uterine rupture.

    One of the perinatologists I work with supports VBAC’s. He said that the pendulum will swing back when women start suing for unnecessary C-Sections. Interesting.

    When we were interviewed recently for an article for the Orange County Register, one of the reporters admitted that the reason they wanted to do a story on MyBirthTeam was because one of her reporter colleagues, who was 38 weeks pregnant, went into her prenatal appointment with her birth plan for a VBAC (first baby was breech) her doctor said “I don’t do VBAC’s” She was shocked. She took classes, joined ICAN, educated herself and assumed that her doctor would be onboard with it. NOPE!

    She was devastated to go in two days later for her scheduled C-Section. She told the OC Register editor that had she known about the matching feature available on MBT she would have chosen a doctor whose services included VBAC’s. She wanted to inform women about our site so that they wouldn’t have to have an unnecessary surgery and recovery. I asked why she didn’t switch, her insurance would not allow it. Unbelievable!

  4. Rachel Says:

    Cyndi,
    Thank you for your comment. I personally think the spectre of uterine rupture helps to perpetuate the liability concerns, in that the slight possibility looms as a Big Scary Thing That Must Be Avoided at All Costs. Thinking that they happen more often than they do feeds the fear that feeds the liability concerns.

    I appreciate your sharing your friend’s experience. While I think some healthcare providers could be considerably more upfront about what the do and don’t “allow,” right now it seems that it lies with women to ask early and clearly about what they can expect.

  5. Cyndi Gross Says:

    You are so right!
    That seems to be the common thread.

    It would be amazing to see what would happen if women educated themselves on the many choices in pregnancy, birth, postpartum, parenting …and heck…life for that matter!

    I hope to see some of that happen in my lifetime.

  6. Margie Says:

    Most of my friends had c-sections and without them, their babies would be dead or severely brain damaged. Perhaps, they are not always a bad thing.

  7. Rachel Says:

    Margie, don’t get me wrong, the point of the post is not that *all* c-sections are “a bad thing.” There does, however, appear to be a preponderance of evidence to suggest that they’re done more often than is truly medical necessary.

  8. Mary Says:

    Thanks for the vote of confidence on the VBAC issue. I’ve had a singleton VBAC and am pregnant again. My Doctor just told me she’s STRONGLY wants me to schedule surgery the week before my due date.

    After reading the post and comments, I’m resoloved to stick to my original plan: Trial Labor with VBAC (No induction) and of course do MUCH more research.

    Thanks again!

  9. Mel Says:

    I agree with Rachel. Of course there are c-sections that are absolutely necessary. However, they are estimating that 30% (and maybe even more) babies are being born via c-section which is higher than what WHO recommends. THEY have turned maternity care into a big business as they do many other things. I read ICAN mentioned. ICAN is a great place for anyone who would like to get more information on c-sections, vbac’s and anything else regarding birth and pregnancy. There are a wonderful group! They’re fighting for our rights to choose what WE want to do with our bodies because what we choose to do with our bodies matters and because ICAN.

  10. Rachel Says:

    Thanks for your comment, Mary – let me know how it turns it out!

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