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Do women need to know the uterine rupture rate to make informed choices about VBAC?

The NIH press release about the VBAC Consensus Meeting includes only a single instance of the phrase “uterine rupture.”  Having spent 2 1/2 days watching the streaming webcast of the event, my strong sense is that this was by design. During the expert testimony, we heard over and over again that uterine rupture is the most feared outcome of a VBAC. We heard in gripping detail what happens when a uterine scar ruptures in labor, and even saw photographs of the devastation. We heard about deaths and hysterectomies and hypoxic injury to newborns that occurred with uterine ruptures.  But after all of that, we heard a rather consistent message that uterine rupture itself is not the issue.

Why’s that? To determine the safety of a practice, it makes sense to look at the death or disability associated with it. Although uterine rupture imposes a high risk of perinatal death, hypoxic injury, and hysterectomy, most uterine ruptures do not in fact result in any of these outcomes. Ruptures are traumatic, devastating, and scary, but they are not in and of themselves “death or disability”. As the lead investigator, Jeanne-Marie Guise said in her testimony to the panel, “uterine rupture is a complex intermediate event.” What women really need to know is, “how will each option affect my health, my baby’s health, and our future?”

This means knowing the likelihood the baby will die or be severely harmed, knowing the likelihood the mother herself will die or be severely harmed, and knowing the long-term consequences of the full range of possible harms. It also, of course, means understanding the benefits of both options. And as obstetrician and bioethicist Anne Lyerly noted in her testimony, everyone applies their own values to the hard data, so two women with the same history and risk factors could make two different choices about mode of birth after a prior cesarean.  These values and preferences were delineated by the panel in it’s statement to the media:

Factors contributing to some women’s desire to attempt a trial of labor include desire for their partner’s involvement in the delivery, belief that labor and vaginal delivery can be deeply empowering, enhanced opportunity for maternal-infant bonding, greater ease in establishing breast feeding, and easier recovery. Conversely, scheduling convenience, the desire to avoid labor pain, fear of failed trial of labor, avoidance of possible emergency cesarean section, and desire for surgical sterilization at the time of delivery may all contribute to a preference for planned cesarean delivery.

All of these are legitimate values, and although as educators and care providers we might explore them with women, we should not ultimately judge them.

Getting back to health outcomes, how did each option measure up? The researchers found that health outcomes for both mother and baby were good in the vast majority of women choosing either option. Maternal mortality and serious morbidity tended to be more common with planned repeat cesarean surgery while fetal/newborn mortality and serious morbidity tended to be more common with planned VBAC. Evidence appeared to strongly favor VBAC when the outcomes in future pregnancies were considered, since life-threatening placental problems and other poor outcomes get more common the more cesareans a woman has had. Many important outcomes, including long-term physical and emotional health, have been studied inadequately or not at all. The panel highlighted multiple critical gaps in evidence and called for more research. For specific findings, you can read the abstract and access the entire systematic review of the evidence here.

Statistically speaking, one of the clearest associations in the data was the small but significant excess risk of uterine rupture in women choosing VBAC. But the excess likelihood of this  “complex intermediate event” doesn’t begin to tell women the whole story. A laser-like focus on this possibility during decision-making obscures the clinically meaningful outcomes that women and their families care about, many of which favor planned VBAC.

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  1. March 11th, 2010 at 06:50 | #1

    “Do women need to know the uterine rupture rate to make informed choices about VBAC?”

    Ask a lawyer. Court cases on VBAC have ruled that it is imperative that women know AND understand the rupture rate.

  2. March 11th, 2010 at 08:12 | #2

    The last thing on a woman’s mind should be legal action, which is one of the biggest problem with this altogether!

  3. March 11th, 2010 at 08:56 | #3

    I deliberately left liability out of this post, although I recognize that it’s the overwhelming driver of the current situation, including the emphasis on rupture in counseling and research. If lawsuits focus entirely on the counseling around rupture rates, and doctors are sued if that counseling isn’t done or documented effectively, then the doctor has a financial incentive to focus on rupture likelihood to the exclusion of other important outcomes in the relatively brief time US prenatal care allows for counseling. (He/she also, as we learned at the conference, has a financial incentive to steer her toward repeat cesarean.)

    Since the situation isn’t likely to change soon, “informed consent” from a legal point of view is likely to continue to be focused on a woman’s understanding of the risk of rupture and its consequences, but “informed decision making” needs to involve people and information sources from outside of the doctor’s office. Lamaze International stated yesterday, and I agree wholeheartedly, that knowledgeable childbirth educators are an important resource for women choosing between planned VBAC and planned cesarean, and in most cases CBEs don’t have conflicts of interest like physicians and midwives do.

  4. avatar
    Rachael M
    March 11th, 2010 at 09:43 | #4

    Oh Dear Dr. Amy,
    maybe your quest should be to explain it to them, since most of your colleagues cannot be bothered to spend more than five minutes a visit with a patient? When you were actually a practicing doctor, did you spend more than five minutes with your patients? It seems like it would take longer than that to explain BOTH the risks and benefits.
    Oh wait. Your opinion is biased and you have no interest in true informed consent, I forgot.
    @Amy Tuteur, MD

  5. avatar
    KK
    March 11th, 2010 at 10:26 | #5

    It is rather arbitrary to focus specifically on uterine dehiscence/rupture with a woman planning a VBAC, since no OB/Gyn ever covers the more common spontaneous occurrences in vaginal delivery (like placenta abruptio or cord prolapse) with a woman planning a vaginal delivery. In a perfect world, a woman would be given ALL the risks and benefits of VBAC vs. RCS by her OB/Gyn, followed by a specific discussion of her characteristics that may make her a better or worse candidate for one method or another. Ultimately, the decision should be left up to the pregnant woman. After all, hospitals hand out the Patient’s Bill of Rights stating that any patient can decline any medical procedure, even if life-saving. And frankly, virtually no woman would decline a Cesarean section that is needed for a grave medical reason anyway. Thus, we’re really talking about women who face the VBAC vs. RCS option with essentially equivalent overall risks.

  6. avatar
    Bonnie
    March 11th, 2010 at 11:32 | #6

    As if one would suppose that an OB/GYN would explain to a woman ACCURATELY that there are LIFE LONG consequences of major abdominal surgery (e.g. bowel obstructions and resulting sepsis, scar issues), ….but wait!!!
    they can’t…its out of their scope of practice. And wait…do we even know the epidemiology of a culture where 50% of the women have major abdominal surgery? Do we know how many of them are likely to encounter problems with their adhesions, and the liklihood they could die as a result of them, and at what age.
    Sure wasn’t part of my informed consent to that cesarean.

  7. March 11th, 2010 at 12:21 | #7

    Women need to know AND understand ALL the risks associated with ANY choice they make – including that of multiple cesareans. The most disappointing part of the draft was the fact that they only included language to warn women of the risks of VBAC, and didn’t require doctors to inform women of the risks of all other birth related catastrophes – most of which are far more common than a uterine rupture. I’m glad someone in the audience brought that point up, but I don’t see anything changing in that arena anytime soon.

  8. March 11th, 2010 at 12:50 | #8

    @Bonnie
    You’re right that OBs in general do not discuss the rare but real potential downstream consequences of surgery, such as adhesions and bowel obstruction. This should be done more clearly.

  9. March 11th, 2010 at 12:51 | #9

    @Bonnie
    Oops I’m talking for all OBs again. stupid me. I don’t think most folks talk about these issues much, as they are very rare.

  10. March 11th, 2010 at 12:59 | #10

    I agree with a lot of you that the VBAC/repeat cesarean consent process is often lacking in the detail it deserves. Realistically one could talk with a patient for an hour or more about the topic. The model that works best for me is to bring it up many times over the course of a pregnancy affected by prior cesarean, so that it can be discussed many times over the course of the pregnancy. The risks of cesarean should be discussed as well as the risks of VBAC, including the differential risks involved when women want to have many many children as opposed to just a few. We do overemphasize uterine rupture at times.

    I was just thinking about how I replied to the issue about bowel adhesions and obstruction with cesareans as a very rare issue and that most OBs don’t talk about it much, and how we do talk a great deal about uterine rupture, also a very rare issue. Perhaps it is because of the temporal relationship of the issue – uterine rupture is right now in labor and adhesion issues would be way down the road.

    A question to be considered is this: how common must an event be for it to be a routine part of an informed consent process? Most courts have ruled that something that can happen 1% of the time or greater should be discussed, and that more rare but serious consequences should also be discussed. Severe adhesions and bowel obstruction are less than 1% in cesarean. Should they be a part of every informed consent? Perhaps.

    Adhesive disease after a cesarean is usually adhesion of the uterus to the anterior abdominal wall, which is not really a big issue. Adhesive disease to the bowel is a more serious concern, but fortunately much less common. Some surgeons choose to use anti-adhesion barriers to prevent these, which at this point is somewhat lacking in long term efficacy and outcome data. This strategy likely would decrease already rare adhesion issues, but is also quite expensive ($300 + per case, $300,000,000 annually if used by policy nationwide)

  11. March 11th, 2010 at 14:55 | #11

    I agree with you Nicholas regarding the 1% rule. By that token, the inaccurate and overbearing counseling regarding uterine rupture is (simply) unjustified. Combine that with the fact that we now have a generation of young doctors with limited experience in VBAC who “feel” that it is much more dangerous than it actually is and we get the failure to offer a procedure which is beneficial (or at least does no harm) in more than 99% of cases.

    Risk tolerance can be affected by how risk is discussed.

    Whenever someone asks me “what’s the worst case scenario for …. ” I usually stop them and say that the worst case scenario for *anything* is death. *Anything*. Accordingly, a more reasonable question to ask is NOT what’s the worst case scenario, but rather what is the most likely outcome and what would the the anticipated spectrum of problems that could be reasonable anticipated.

  12. avatar
    Karen
    March 11th, 2010 at 15:20 | #12

    Yes, women should be informed about risk of rupture, I don’t see how a woman could have informed consent without understanding rupture BUT that is also understanding the difference between catastrophic rupture and asymptomatic dehissence and the possibilities in between. VBAC, like so many health decisions, is not black and white. There are risks in choosing that path and choosing another one (ERCS), how about we give TRUE informed consent. Not sugar coating the risks of VBAC but also not overstating the risks. It seems the rare practitioner that finds that balance.

  13. avatar
    Karen
    March 11th, 2010 at 15:32 | #13

    Regarding not discussing other, more common, complications of pregnancy such as cord prolapse or placental abruption, like UR is talked about in VBAC. I would say because a woman is making a choice and that choice may have the consequence of a uterine rupture. Cord prolapse usually isn’t discussed until someone brings up AROM when the woman must consent to an intervention/choice that may lead to it. There is no point where a woman must make a decision that will increase her risk of abruption. She doesn’t need the risk vs. benefit scenario as she can take no action to change whether or not she has an abruption. That isn’t the case when a woman is choosing VBAC or ERCS. Her decision may have consequences, in many/obstetric emergencies nothing the woman did or can do will change anything.

  14. avatar
    KK
    March 11th, 2010 at 15:38 | #14

    But would it be relevant to discuss placenta abruptio, cord prolapse, even vaginal tearing to a first-timer choosing between a vaginal delivery and an elective C-section? It might affect her decision. Or is it only consequences of VBAC vs. C-section that are worth emphasizing (specifically UR in current practice)?

  15. avatar
    KK
    March 11th, 2010 at 15:45 | #15

    I don’t know if my post came out right, but I guess I was trying to say that the focus on UR in VBAC seems unusually intense, since we don’t emphasize all of these awful vaginal delivery catastrophes to first-time mothers who could elect C-section instead or could sue if their vaginal delivery went horribly wrong. We usually assume they will have successful vaginal deliveries (even though she won’t 30% of the time).

  16. March 11th, 2010 at 17:24 | #16

    Karen >> Yes, women should be informed about risk of rupture, I don’t see how a woman could have informed consent without understanding rupture BUT that is also understanding the difference between catastrophic rupture and asymptomatic dehissence and the possibilities in between

    I don’t think most OBs would consider a scar dehissense as a uterine rupture, and doubt that in rupture stats those are counted either. From time to time one does a repeat section and sees that the lower uterine segment has stretched open and all there is between the baby and the abdomen is peritoneum. I’ve never heard anybody call this situation a uterine rupture. We don’t call it a scar dehissense either though – in my experience its generally referred to as a uterine window.

    KK – I think you make a very good point. We don’t generally consent patients for vaginal delivery, as is the natural state of affairs and not an elective procedure. One could argue that perhaps we should, as there is the alternative of elective cesarean delivery. I’ve always felt though that it was like consenting somebody to breathe – its going to happen whether we like it or not, so why bother asking permission.

  17. March 11th, 2010 at 18:26 | #17

    I just posted a new piece on how micro tort reform could potentially solve VBAC liability and thus VBAC availability. Please read and comment!

    http://academicobgyn.com/2010/03/11/micro-tort-reform-a-potential-solution-to-the-vbac-liability-issue/

  18. avatar
    Margaret
    March 12th, 2010 at 00:32 | #18

    I like your perspective Dr. Fogelson on how a discussion of the risks and benefits should be handled. I just had a successful VBAC and had a supportive hospital and a wonderfully supportive OB. We talked about the benefits and risks of VBAC v. ERCS at many of the earlier appointments at length. I decided to VBAC as it was only my second child and my husband and I were hoping for a large family. Once all the possible outcomes had been discussed, my OB was very supportive of my decision and did his best to help me make it happen, which is saying a lot because he doesn’t have any partners. This format was ideal, but I don’t know if it would be possible in every circumstance, the OB had 20-30 min budgeted for each prenatal visit, more for the first one or two.

    As someone with an MPH in health education, risk communication is of great interest to me. Risk communication and informed consent is something that could never be perfect, there are too many human factors Humans in general have a hard time putting risks in perspective, and we are all prone to overestimating and underestimating risk. I will definitely check out your article Dr. Fogelson.

  19. March 12th, 2010 at 12:51 | #19

    I believe woman should be informed of the uterine rupture rate, but sole focus should not be placed on uterine rupture. The value of understanding the rupture rate is that it can put VBAC risks into perspective when you compare the risk of uterine rupture to other serious complications of childbirth, such as cord prolapse or placental abruption.

    Just as we would (or should not) obtain an informed consent for c-section without realistically presenting the potential risks, we should not obtain consent for VBAC without a similarly realistic discussion of risk. Emphasis on one complication and exclusion of fair discussion of other complications is sometimes used to sway the woman toward the decision the provider wants her to make. Informed decision making needs to be done in a very neutral, factual matter, and presenting the uterine rupture rate is part of this.

  20. avatar
    Marjorie
    March 14th, 2010 at 19:38 | #20

    “Factors contributing to some women’s desire to attempt a trial of labor include desire for their partner’s involvement in the delivery, belief that labor and vaginal delivery can be deeply empowering, enhanced opportunity for maternal-infant bonding, greater ease in establishing breast feeding, and easier recovery.”

    Maybe these factors have a play in the decision to VBAC. For my successful VHBAC the reasons that meant the most to me were:

    1) To ensure a term birth by beginning labor naturally.

    2) To ensure that I was able to labor and birth in the position most comfortable for me.

    3) To ensure that oxytocin would be used only in the event of PPH in order to protect my uterus.

    4) To ensure that my labor and birth took place in a supportive environment.

    5) To ensure that my baby risk of lung problems/NICU admission would be lowered.

    6) To reduce the risk from cesarean section and it’s complications (to me) including death.

    7) To reduce the risk of injury to my baby from drug or surgical complications/mistakes.

    8) To reduce the risk of PTSD and marital stress resulting from iatrogenic “emergencies”.
    IOW-Active Management.

    9) To remove my labor from the clock and the bunk Friedman curve.

    10) To avoid the temptation of the epidural which can slow labor and generally keep you in bed.

    11) To avoid AROM.

    12) To avoid VE’s.

    13) To have access to doppler monitoring.

    14) To avoid an IV unless needed for hydration.

    15) To ensure a natural 3rd stage of labor.

    16) To ensure constant, vigilant, personal watchful waiting on the part of private medical personnel.

    17) To catch my own baby. (If I can do it anyone can!!!)

    The reality is that this type of care is usually restricted to those who hire a private midwife who is willing to attend a home birth.

    When institutions can offer this type of VBAC, I’ll be back.

    It’s a shame

  21. avatar
    Marjorie
    March 14th, 2010 at 19:56 | #21

    -@Karen

    “There is no point where a woman must make a decision that will increase her risk of abruption. She doesn’t need the risk vs. benefit scenario as she can take no action to change whether or not she has an abruption.”

    I may be wrong on this but it’s my understanding that induction/augmentation contributes to abruption, and it was a risk discussed with me during my last hospital birth. So to refuse induction/augmentation would lower the risk of abruption.

  22. avatar
    Emily
    March 15th, 2010 at 23:43 | #22

    Uterine rupture take place during labour and OB’s see the consequences. Many of the possible consequences following c-section aren’t seen until much later. It seems to me that the women that I’ve known who had c-sections were fine until they got home. I would guess that from OB’s perspective, they mostly see the immediate consequences and their focus will be on what they see and not on what happens after they leave. Which is only human.

  23. March 16th, 2010 at 09:20 | #23

    In order to make an informed decision a woman should know EVERYTHING! Great blog

  24. May 17th, 2010 at 08:10 | #24

    I am a pediatrician who read all the studies faithfully before choosing a VBAC for my second child. I had a CS due to breech with my first. I chose to VBAC for all the reasons you mention including empowering birth, better for future pregnancies, less risk of iatrogenic harm, less surgical risk. I figured the risk of UR was lower. It may be, but let me tell you, the overwhelming maternal guilt and PTSD that you feel after YOU are the statistic that has the rupture, and your baby is born still and has to be resuscitated with brain injury, is NOT empowering. I still think women should have the choice to VBAC but to talk about not informing them of the risk of UR is ridiculous. No matter how rare, it is the complication most likely to end up with a dead baby, frankly. And this is any mother’s MOST feared outcome. Just my perspective from the sad other side of the statistic. Oh, and by the way, I had no induction and went into labor at home, very fast labor and was bleeding out by the tiime we made it to the hospital and they saved our lives. So, can’t blame the docs.

  25. avatar
    jasmine
    June 8th, 2010 at 02:04 | #25

    I nearly died from a uterine rupture when i was 19. my uterus, however, had been damaged from cancer treatments that i had received years previous, not from a c-section. However, no one ever talked with me about the potential for this complication, and when I went to my care giver three times that week, telling him that something was terribly wrong, he didn’t listen. I probably should have died, But i was diligent. I knew that something wasn’t right. i went to the hospital and demanded an airlift to Seattle, which they agreed to after my blood pressure continued to drop. Being proactive, even amongst the negativity from my health providers, is what saved my life. so, talk to the women….tell them to Listen to their own bodies. and, Listen to all of their concerns. my child died, and i lost my uterus as well. I wonder what would have happened if my providers had listened, had taken me seriously? I am a strong supporter of natural births, but I am also feel that if there is any potential for uterine rupture, it is important to be Very near a surgical hospital. after a rupture occurs you have only minutes to save the lives of both the woman and the baby….

  26. avatar
    Carrie Haire
    September 13th, 2010 at 09:33 | #26

    @chukwumaonyeije
    Hello, I am writing you with a concern that i have. I am 33 and have 3 living childern, 3 repeat sections being atleast 3 years apart and the last over 6 years ago. I was told by my DR during my 3rd that i should tie my tubes, as more then 3 sections was a very high risk. During the 3rd section, my DR noted very thin uterin window (said that he could see the baby), also lots of scare tissue and the bladder was adheared to the uterus. He also notice a “runt” in the bladder that had to be reparied. Well, Needless to say he did tie my tubes that day… It is 6 years later and I want another child. Other than the noted problems with my 3rd section, i have no health issues at all.. i do not drink, smoke or have any other issues that i see a Dr for. I am wondering WHAT the chances are that I could carry another child? Thanks so much for youe time!

    Ps, I do understand that I would need to have IVF completed if i were able to carry another child.

    Thanks again,

    Carrie

  27. avatar
    Nikki Eneff
    September 15th, 2010 at 23:05 | #27

    Carrie, I could have written your post aside from having my tubes tied, because I refused. The doctor doing my c-section talked about my uterine window while operating, but refused to discuss it with me afterward. I was patted on the hand and congratulated. He continued to patronize me throughout my stay in the hospital. I have not had a chance to discuss it with my family doctor yet (she was the one taking care of me during my last pregnancy), and probably need to discuss it with an OB as I’m not satisfied with why. I was told to seriously reconsider my desire for more children because of a uterine window. I’m very disappointed with the lack of communication from either of the doctors. I will certainly weigh the risks, but as a patient I expect to have more of a conversation about why my dreams for a big family are not going to happen than, “well, you had a uterine window, so you should probably not have any more children.” To have such important dreams potentially snatched away in a conversation that lasted a minute and half is just really disappointing.

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