My name is Debby Miller. I am a thirty something mother
of two boys. One born by caesarean and the other a
I work full time as a financial adviser in a Government
Department and am currently studying two degrees Accounting
and Human Resource Development. From my work and study I
have developed a good ability to research things. A skill
that was particularly helpful to me when I was researching
for my VBAC birth.
I have a great interest in birth issues, particularly
related to being an informed patient because of my first bad
birth experience and my subsequent good one.
I have offered to write a series of articles about a
variety of subjects for Birthrites in the hope that my
experiences and investigative abilities can help other
mothers and mothers to be to make informed decisions about
their birth choices. The topics I intend to write about are
shown in the Discussion Topics Index. I will not be writing
them in any specific order or to any specific time frame.
I would advise all readers to read the first article
Believing What You Are Told as this provides the basis for
you to understand how assessments are made, both by myself
and in the references I use, on the remainder of the topics
I will try to keep the articles simple and will provide
examples where possible. If medical terms are used I will
add them to the Glossary so you can see what they mean.
I would ask that readers note that I will try to keep the
research factual and not input my own personal bias, however
whilst I am aware of my own prejudices, I will probably lean
towards documentation that supports my view.
Secondly I am not a medical practitioner, nor do I have
any medical training. The information I present will be
based on research, journal articles and texts, and my
interpretation of those. I will quote all references.
Women wishing to use the information I provide are
recommended to read the references for themselves and should
discuss any issues pertaining to their own medical
management with a qualified medical practitioner or
A Quick Anatomy Lesson
In introducing the topic of uterine ruptures we first
need to have a bit of understanding of how the uterus works.
The uterus has three sections:
The upper segment Also called the fundus. This
area is the main body of the uterus in which the baby grows.
The upper segment is made of a criss-cross of muscles on the
outside and the endometrium (lining) on the inside. In the
majority of pregnancies this is the area where the placenta
is attached. During labour the muscles of the upper segment
contract. With each contraction the muscle fibres get a
little shorter. This results in the lower segment being
pulled upwards and causing the cervix to open.
The lower segment The lower segment is the area
that joins the upper segment to the cervix. It has a
relatively lower blood supply than the upper segment. In
the non-pregnant woman and the early stages of pregnancy the
lower segment is hard to distinguish from the cervix as it
is so small. In late pregnancy the lower segment starts to
stretch upwards as the baby grows and can be clearly defined
by the end of the third trimester. It is through the lower
segment that most csecs are done these days as the risk of
bleeding is significantly lower. During labour the lower
segment is stretch up by the contractions of the upper
segment and this causes the cervix to open. By the end of
labour (full dilation) it is very difficult to distinguish
the cervix from the lower segment.
The cervix is the band of tissue which keeps the
uterus closed during pregnancy. During labour the cervix is
stretched open by the pulling on the lower segment from the
contractions and by the pressure of the baby's head. By the
end of labour (full dilation) the cervix will have stretch
to a diameter of 10cm and the baby's head can then pass
through into the vagina and the outside world.
What are Ruptures and Dehiscence?
A rupture is a 'disturbance' in the wall of the uterus.
It may be minor when it is also known as a dehiscence or
window or it may be major. A dehiscence or window usually
refers to an opening that is very small or does not go
through all of the layers of the uterus.
A rupture is a large tear that goes through the full
thickness of the uterus.
Where do Ruptures and Dehiscence Occur?
A rupture can occur anywhere on the uterus. The two most
common sites are where there is an old scar or at the line
where the lower segment joins the upper segment. Just
because a woman has had a previous csec does not mean she
will rupture at the site of the scar. In one study (ref 23)
only 68% of women with ruptures ruptured at the site of
their previous scar.
When do Ruptures Occur?
Ruptures can occur before or during labour. The
statistics for this are quite divergent. In one study (ref
4) they indicated that 10% of ruptures occurred before
labour commenced. In ref 10 they quote a study in which 23%
of ruptures occurred before labour started and they quote
the American College of Gynaecologist who state the rate is
as high as 50%.
What happens if there is a Rupture or
If a dehiscence occurs usually nothing happens. The
majority of them are found after successful vaginal birth
when the doctor feels inside the uterus (not a common
practice any more and it is not recommended as it increases
the risk of infection with no appreciable benefit).
Occasionally they are found in women having an elective
repeat csec and in women having an csec after failed VBAC.
All the writings I read indicate that there is usually no
action taken to repair them as they tend to heal well by
themselves, and it is acknowledged they present no risk to
the mother or baby.
Ruptures can occur in the upper or lower segment or where
the two join. A rupture in the upper segment is the most
catastrophic as this area has a large blood supply. If a
rupture occurs the baby may move out of the uterus into the
abdominal cavity. This is very dangerous for both the
mother and the baby as it places tension on the placenta,
which can cause it to separate from the uterine lining. If
this occurs the mother will lose even more blood and the
baby loses its oxygen supply. (Fortunately the incidence of
this is very low and is explained later in this
A rupture in the lower segment is less catastrophic as
this area has a lower blood supply and the bladder will
inhibit (but not necessarily stop) the ability of the baby
to leave the uterus. This is however still an emergency
situation requiring immediate intervention.
How Accurate are Doctors at Identifying
I could only find one study,(in Massachusetts ref 23),
that addressed this. Over a seven year period they had 1244
cases that were identified as suspected dehiscence (in this
study dehiscence was used to describe both windows and
ruptures), of these only 480 (38%) were confirmed as uterine
ruptures. The literature suggests that the incidence of
picking up a true rupture is very high however the incidence
of mistaking certain symptoms for a rupture when there isn't
one is also very high.
What are the Symptoms of Rupture or
With a dehiscence there are usually no symptoms at all.
In some cases it is believed that the window is actually a
failure of the csec scar to heal rather than as a result of
the pressures of labour. Reference 12 indicates there is no
risk to the mother or baby.
If a rupture occurs there can be a number of symptoms.
All or none of these may be present (refs 1,2,4,11, 20 and
the symptoms are:
a. vaginal bleeding
A small amount of vaginal bleeding during labour is
normal. Your birth attendants will know if the amount is
excessive or not. Vaginal bleeding can also occur where the
placenta partly or fully detaches from the uterusbefore the
baby is born (this is not a rupture but is an emergency) or
where there is a tear in the vagina or cervix from the
pressure of the baby or from attempts at instrument
deliveries (forceps and vaccuum).
This is low blood pressure, it causes dizziness and
lethargy and occurs during ruptures because of blood loss
but can also be caused by epidurals, laying down or from
c. cessation of labour
Labour may cease during a rupture because the muscle
tissues that have torn areno longer able to contract.
Labour may also cease if there is a false labour, the mother
is nervous or tense and some labours are known just to
d. loss of intra-uterine pressure
This is were the contractions diminish in intensity (or
stop). The reasons for this are the same as for cessation of
e. abdominal or uterine pain
During a rupture this pain may occur for two reason,
firstly the tear itself and secondly because blood loss into
the abdominal cavity irritate the lining of the cavity.
Abdominal pain may also occur as part of normal labour
(because contractions do hurt) or because of wind in the
bowel or constipation.
f. fetal distress
Where there is a loss of fetal heart rate, a prolonged
deceleration (down to 90 beats per minute for more than one
minute) or persistent late decelerations there is an
indicator that the baby is not receiving enough oxygen for
some reason. This may be due to rupture, a problem with the
placenta, pressure on the cord, low blood pressure in the
mother or a whole range of other reasons.
g. uterine fundus may feel boggy
The uterus normally feels like this after delivery of the
baby. It feels like this and tender after a rupture when
the baby has partly or fully 'escaped' from the uterus into
the abdominal cavity.
h. The fundus may seem to be expanding
This can occur because the cavity is filling with blood
from a rupture or because expanding the baby is turning.
i. The woman is aware of something
This may be because of a rupture or it may just be from
the baby moving down 'having given way' inside or gas or
faeces moving through the bowel.
j. When examining the abdomen the baby can be felt
The sensation of feeling a baby inside the uterus and one
in the abdominal cavity is quite different according to a
number of the references. This would therefore only occur
if the baby has escaped through a rupture or had grown
outside the uterus (extremely rare I have only read of two
cases in the world).
k. The woman goes into shock.
This occurs during rupture from blood loss, low blood
pressure and possibly from pain. Shock can be caused by any
number of things including emotional trauma ie if the mother
is particularly frightened during the labour (this causing
shock however is very rare. ) Shock can be a life
threatening condition it should therefore be treated
l. Maternal tachycardia
This is fast heart rate (usually above 120 beats per
minute in an adult). this is a symptom of shock but can
also occur during times of physical exertion (particularly
if the mother is unfit) or when the mother is anxious.
Which Women Have Ruptures?
Any woman can have a rupture. This includes women who
have never had a csec before. The risk to some women is
however higher than for other women. Here is a breakdown
- vertical lower segment 1 - 7%
- T or J incision 4 - 9%
- The risk for women who have had five or more
pregnancies (grand multiparity) is also recorded as being
higher there were no quoted statistics in any of the
articles. In ref 20 they had 13 ruptures and 2 of these
were due to grand multiparity.
- There is also a risk of rupture where there is a
trauma to the abdomen. A number of the studies cited
ruptures resulting from vehicle accidents.
- If you had a first trimester abortion (at some time)
your risk of rupture is 1%
- If you have had a hysterotomy or uterine operation
(eg fibroid removal) your risk is 6%
Of all uterine ruptures recorded in four
Study one 42 ruptures 71% VBAC 29% in unscarred
Study two 23 ruptures 43% VBAC 57% in unscarred
Study three 480 ruptures 92% VBAC 7% in
1% in non csec scarred uterus
Study four 81 ruptures 89% VBAC 11% in unscarred
(These studies do not breakdown what types of scars the
VBAC had and do not distinguish between ruptures and
It should be noted that in a number of the references
there was no indication if the women who were recorded with
ruptures had been in labour or not.
I could not find any studies in references that indicated
a higher risk of rupture in women with macrosomic (large
over 4kg) babies, twin pregnancies or breech deliveries. Ref
33 indicates there were no significant differences in death
or injury in VBAC women with babies over 4kg, it also
indicated of the recorded twin VBACs there were no ruptures
and of the recorded breech there were no significant
differences, however it indicated the preference was to do
external version on breech babies. (Also a safe practice for
Can They Predict If I Will Rupture?
Ref 10 quotes a British study that involves measuring the
thickness of the lower uterine segment by ultrasound late in
the last trimester of pregnancy (over 35 wks). The study
indicates that in women with the thickest lower uterine
segments there is a very low chance of rupture. However the
study also acknowledges that even for women with the
thinnest lower uterine segments the risk of catastrophic
rupture is still very small and can be offset with vigilant
There are no major studies on the identification of a
dehiscence however in this same study the sonographers
believed they would be able to see dehiscence at the scar
site using ultrasound. Given that dehiscence are considered
benign I would wonder what the benefit of this would be as
there are no studies that correlate the presence of
dehiscence with a higher rupture rate, (mind you there are
also none that disprove it either).
What Causes a Rupture?
The simple answer here is we do not know. We know
certain factors increase the risk but we do not know why
some women have ruptures and others with similar histories
The main factor that has been identified as increasing
the risk of ruptures is the use of inducing drugs, oxytocin,
prostaglandin and pitocin. A number of the studies indicate
statistics associated with the use of these:
- 6 ruptures 4 (67%) had pitocin (ref 7)
- 17 ruptures 9 (53%) had oxytocin (ref 13)
- 31 ruptures 10 (33%) had oxytocin and 4 (13%)
had pitocin (ref 17)
- 13 ruptures 4 (31%) had oxytocin and 3 (23%)
had prostaglandin (ref 20)
It should be noted that none of these studies indicate
the amount of the drug these patients were given. This is a
very important factor as there is a huge difference in the
intensity of contractions depending on the rate of induction
with oxytocin, and pitocin and prostaglandin have been known
to bring on very strong contractions after more than one
dose. In support of this ref 5 and 8 both recommend extreme
vigilance where more than one dose of pitocin is used, and
all of the above references recommend careful monitoring
and/or observation of induced women, in particular VBAC and
but also non VBAC.
In contrary to these studies, the study in ref 12 found
no increased incidence of rupture between those mothers who
did and did not receive inducing drugs, and the findings in
the study in ref 24 were inconclusive but recommended a
proper trial be done on prostaglandins.
Ref 9 raised a very important issue, that is the overuse
of induction agents. The author indicates that a number of
studies have shown that TOL VBACs ' often have a stop-start
labour and they are 'classically slow '. The author goes on
'There is an overuse of induction drugs in an attempt to
speed up and 'normalise' the labours of TOL VBACs. It is
documented that in TOL ', it is stated that 'women's bodies
seem to know that too much stress is bad for their scarred
uteri. Yet instead of trusting VBAC mother's bodies
intuitive attempts at gentle birth, drugs are given to
normalise and speed up the birth process thereby creating
more risk of uterine rupture.'
(I would agree with this principle of your body knowing
what it is doing. My VBAC started went for 10 hours,
stopped for 6 hours restarted, took another 15 hours to get
to 4 -5cm then another 12 hours before my healthy son was
born. No rupture, no induction, happy Mum.)
I found no studies that indicated epidurals or any other
form of pain relief was associated with increased ruptures.
Nor was any of the other 'things' Mums do in labour, eg.
Walking, showering, bathing, eating, drinking, massage,
Ref 28 investigated the position of the placenta in
relation to rupture sites. They found that of 42 VBAC
ruptures, that ruptured at the site of the scar, the
placenta was at the site of the rupture in 60% of the cases.
They concluded that the position of the placenta may play a
role in uterine rupture but indicated further studies were
needed to prove this.
What Do they Do If They Suspect a Rupture?
A rupture can (in some cases) result in the death of the
baby and/or the mother. The suspicion of a rupture is
therefore treated very seriously. All of the references I
read recommended immediate action and caesarean section.
The types of actions that may be taken included putting in a
drip (if there isn't one) to give the mother fluids and
possibly blood, administering oxygen by mask and rolling the
mother onto her left side. During this time they would also
be monitoring the mother's blood pressure and pulse, and the
babys heart rate either with an electronic monitor, scalp
monitor or by a hand held monitor. They may try to prevent
the baby from 'escaping' the uterus by manually holding the
baby in the uterus and preparation would be underway to give
the mother general anaesthetic so the baby can be delivered
by emergency caesarean section very rapidly. (Ref 1, 2, 3
What are the Outcomes of Ruptures?
Thankfully the majority of women who experience a rupture
leave the hospital with themselves and there babies intact.
There are a number of possible procedures that may/will need
to be done in the event of a rupture.
It is likely the mother will need the rupture repaired
(unless it is found at the time of csec it is only a
dehiscence or nothing at all, but even then they will still
need to repair the csec incision), she may need an arterial
ligation which is where they clamp an artery for persistent
bleeding, and in the worse cases (where the bleeding cannot
be stopped) she may need a hysterectomy. There are cases of
mothers dying from ruptures (very few as you will see
below), the primary cause of death in these cases being
cardiac arrest from blood loss. (Ref 1)
The outcomes for the baby are simpler but possibly longer
lasting. In most cases the baby is perfectly fine. In some
cases the baby may suffer some brain damage due to oxygen
deprivation, (particularly if they partially or fully
'escape' from the uterus and therefore compromise their
placenta), the degree of damage can vary depending on the
length of time they were without oxygen and the strength of
the baby. (It should be noted that even babies who aren't
subject to a uterine rupture can suffer oxygen deprivation
in some circumstances, including csec babies). The worst
that can happen is the baby will die, usually because its
placenta detaches from the uterus and their oxygen supply is
completely cut off.
So how often do these things occur:
Study 1 9 ruptures 2 still born (22%)
(of the nine ruptures there were 2 classical csecs and 6
LSCS and one non scarred, the study does not say which of
these mothers lost their babies)
0 hysterectomies and 0 maternal deaths
Study 2 155 ruptures 8 fetal deaths (5% - 5
occurred in mothers who arrived at hospital ruptured)
1 maternal death (doesn't indicate if this was a TOL or
Study 3 17 ruptures 0 deaths 8
hysterectomies (ref 13)
Study 4 1 rupture 0 deaths (this rupture was in
an elective repeat csec)
Study 5 23 ruptures 0 deaths
Study 6 13 ruptures 0 deaths
Study 7 8 ruptures 1 fetal death (12.5%) 2
severe fetal asphyxia (oxygen deprivation) 3 bladder
lacerations 1 hysterectomy
Study 8 10 ruptures 2 fetal deaths (20%)
Study 9 81 ruptures 2 maternal deaths (2%) (these
were a mix of scarred and unscarred uterus) 14 bladder
injuries 12 hysterectomies 5 fetal deaths (6%) 14 neonatal
deaths (17% - after birth deaths - the cause of these deaths
is not given) 59 fetal brain damage (72% - the degree of
damage is not indicated and it does not indicate if the 14
neonatal deaths are also included in this group)
If we add all of this up we have 317 reported ruptures,
30 (9.5%) fetal death rate, 3 (0.95%) maternal death rate
and 61(19%) of babies with some degree of brain damage from
oxygen deprivation (this may be minor or major).
To put this into perspective given that the VBAC mothers
risk of rupture is around 1% , you have a (0.095%) chance of
your baby dying due to rupture in any VBAC delivery, a
0.0095% of you dying due to rupture in any VBAC delivery and
a 0.19% chance of your baby suffering brain damage due to a
rupture in any VBAC delivery. (Contrast this to the other
risk identified below).
The studies all indicated that one of the primary causes
of death amongst mothers and infants was mismanagement by
hospital staff. A number of the reports sited ignorance
among staff of the symptoms of rupture and/or a slowness to
act thus compromising both the mother and the child. The
generally agreed treatment was that csec needed to be
conducted within 30 mins of suspected rupture with some
practitioners indicating this figure should be closer to 17
What Can Be Done to Reduce the Risk of
Either you are going to have a rupture or you are not.
There is nothing with the possible, exception of refusing
induction agents, that you can do that will reduce your
personal risk of rupture.
The key thing in deciding what sort of birth you want to
have is to make a conscious decision of the risk YOU are
willing to take. To put this into perspective lets look at
some comparative risks.
- Your risk of rupture from a horizontal LSCS scar is:
1% = 1 in 100 VBAC deliveries (this is the highest
- Your risk of being diagnosed with dystocia (baby too
big) is: 10 - 12% = 10 in 100 vaginal
- Your risk of a breech baby at full term is: 3 -
7% = 3 in 100 deliveries
- The risk of your baby being diagnosed with fetal
distress during labour: 2% = 2 in 100
- Your risk of having twins is : 0.4% = 4 in
- Your risk of dying from a rupture of the uterus is:
0.0095% = 9.5 in 100 000 VBAC deliveries
- Your risk of dying during any vaginal delivery is:
0.0098% = 9.8 in 100 000 vaginal deliveries
- Your risk of dying during an uncomplicated vaginal
delivery is: 0.0049% = 4.9 in 100 000
uncomplicated vaginal deliv.
- Your risk of dying during any ceasarean section is:
0.0409% = 40.0 in 100 000 ceasarean sections
- Your risk of dying during an elective repeat
ceasarean section: 0.0184% = 18.4 in 100 000
- The risk of your baby developing cerebal palsy is:
0.25% = 2.5 in 1000 births
- The risk of your baby developing cerebal palsy after
fetal distress: 2.84% = 2.8 in 100 fetal distress
- The risk of your baby dying from a rupture of the
uterus is: 0.095% = 9.5 in 10 000 VBAC
- The risk of your baby dying during any VBAC delivery
is : 0.2% = 2 in 1000 VBAC births
- The risk of your baby dying during any type of
delivery is: 0.12% = 1.2 in 1000 births
- Risk of losing the baby in a breech delivery is: 1
- 4% = 1 in 100 breech deliveries
(ref 10, 33)
Of 873 fetal deaths in the UK during 1994 - 95, 42
(4.8%) were due to uterine rupture 30 of these were in
mothers with a csec scar and 12 were in unscarred uterus.
As you can see the risk of you or your baby dying from a
uterine rupture is no higher and in some cases lower than it
is from 'normal' or caesarean delivery. All births have
some degree of risk even if you have a perfect history, the
key thing is to identify what you consider too great a risk
and then take actions so that you can receive the best
possible care if your worse case happens. The big thing to
remember when putting this in perspective is that sometimes
(thankfully rarely in western countries) mothers and babies
die both at hospital and in home births. There are risks of
being in hospital (such as the higher chance of intervention
and infection) and risks with being at home (such as longer
time to get to a place where you can receive emergency
resuscitative procedures). It is up to you where you think
you will be safer, and what sort of labour you think will be
safer (ie. with or without interventions). From the
statistics you can see that any doctor that tells you that a
certain way is risk free is lying. The only risk free way
to have a baby is to adopt.
The best thing you can do if the risks really worry you
is to ensure you are in an environment where if a rupture
does occur it can be promptly dealt with. This environment
would usually be a hospital or a birthing centre. If you are
in hospital you may ask for intermittent or continuous
monitoring, which is the most reliable (but not 100%
accurate) in the indication of a possible rupture.
Monitoring can also be done during birthing centre and home
births but it is usually intermittent with a stethoscope for
fetal sonagraph. Other actions such as epidurals and drips
will not make an emergency caesarean any quicker. An
emergency caesarean from a rupture would normally be done
under a general anaesthetic anyway, and a drip can be put
into a person in a couple of minutes or less.
A rupture of the uterus is a very serious condition that
needs to be dealt with immediately to save both the mother
and baby, however it is rare. Being a VBAC mother does not
mean you are the only one who is at risk of a uterine
rupture, any woman with or without a uterine scar has some
risk of having a rupture.
The likelihood of a fatal outcome from a uterine rupture
is no higher than the general incidence of death in all
births and is lower than that for caesarean births.
It is recommended that you discuss this issue with your
medical practitioner or midwife. They may provide
additional studies that counter these findings however the
facts found by myself indicate that the risk of uterine
rupture in a VBAC birth is very low and the risk of an
adverse outcome even lower. In fact these results seem to
be no worse than for other means of delivery and for other
possible birth complications that can happen to any
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