Monday, November 19, 2012

Fear of Rupture

I received a Facebook message from someone wanting to have a VBA2C, but dealing with a lot of fear.  I sent the message on to Abbey Robinson. I asked if I could post it here.  I hope you will find it helpful if you too are wanting a VBAC but dealing with the fear that is spoon-fed to our VBAC mamas.

First of all, congratulations on your pregnancy.  I, personally, had a VBA3C so I can definitely understand where you are coming from.  VBAC is a huge commitment and learning everything you can about the process is crucial to success.

I think that it’s normal to be fearful when you hear so many scary stories on the internet and through friends, family, and acquaintances.  From what I am hearing, your major concern is that you may not know/feel when/if you have a uterine rupture.  I will try to address this for you.

I never speak in absolutes regarding anything, so I’m not one of those people who will reassure you that there is no risk and everything will be fine.  Simply being pregnant and carrying a baby has risk.  Having a 3rd c/section places you at risk for many complications, much more than your 1st c/section would have been likely to cause.  Your risk of 
•    major complications is a whopping 7.5% (including but not limited to are listed as  uterine rupture, hysterectomy, additional surgery due to hemorrhage, injury to the bladder or bowel, thromboembolism, and/or excessive blood loss.)
•    Placenta accreteta: 0.57%
•    Risk of hysterectomy: 0.9%
•    Risk of blood transfusion: 2.26%
•    Risk of dense adhesions: 32.2%  (can cause life long pain/bladder and bowel problems/back pain (from everything sticking together) and will heavily complicate any future c/sections)  If you want statistics on a 4th c/section (if you plan to have more children, let me know.  The risk goes up many more times for each complication)

That leaves you with VBA2C and the risk of “uterine rupture”.

There was an Australian study of over 29,000 women who spontaneously went into labor where the risk of UR without augmentation (pitocin, prostaglandins, cytotec, etc.) with one prior incision was found to be a very low 0.15%  Once you introduce labor augmenting and induction drugs, the risk of uterine rupture increases to 1.91%.  HUGE difference.  From the studies that have been done on VBA2C or more, there isn’t much difference in the UR rates.  Cochrane reviews have identified true UR rates to be around 0.4% when no augmenting drugs were used.  Most of those cases were uneventful and mother and baby were healthy and fine.

SOOOOO, now that we’ve established that statistically, you have much better odds of having a VBAC with no uterine rupture than the risks of having a 3rd c/section, let’s talk about what you might feel and how to identify a UR.

Much of what we refer to as ‘uterine rupture’ is what is medically known as ‘dehiscence’ or a ‘uterine window’.  This is where the scar tissue begins to separate but a thin piece of tissue is left so the muscle doesn’t completely rupture but it’s so thin you might even be able to see through it.  Even though this ‘window’ is included in the statistics for ‘rupture’ when it is identified (usually when a mother is having a RCS either scheduled or after a trial of labor) It has mostly been found as harmless…usually no repair or special care is needed and it heals on it’s own.  There’s not enough information to know if it increases your risk of rupture for the next pregnancy or not.  But if you didn’t have it last time, there is no reason to believe you will this time.

Sometimes a rupture is painful.  Sometimes there is absolutely no doubt that you are having one, but as you have found out, it’s not always that way.

What WILL happen is your body will act differently.  If your uterus has a tear, it will not function like it did before.  It may become boggy and limp.  It may suddenly change shape.  You will probably have actual bleeding (bright red blood rather than normal bloody show).  As long as you are not medicated (don’t have an epidural or narcotics) you will feel that something is different. 

Much of the time, when a mother goes back for a section and there is a dehiscence, the OB will make a point to tell the mother that her uterus was rupturing, she is then terrified into scheduling a RCS for any future births.  The OB only knows what he has seen and the mother only knows what she is told and even though there was no negative outcome, both are scared of VBAC from then on.

As long as no harm was done, there is no reason to assume that it’s a dangerous situation.  The pregnant body is AMAZING, and if there is a problem with your uterus, most of the time it will send that signal to your body and labor may slow or even stop to protect itself.  Contractions may space out and be gentler on you than if you didn’t have a scar.  Embrace it and enjoy your labor.  Even when babies are stressed out, the body will get the message and contractions will not intensify, changing positions will get things going again, because baby is getting more oxygen and sending the signal to get going again.

NOW, catastrophic uterine rupture is what we are really afraid of.  It’s what we always *think when we hear the term “uterine rupture”.  This is when the baby literally breaks the uterus and is born into the abdominal wall.  You better believe that this will be painful and you will bleed and this is very scary and dangerous.  It accounts for a VERY VERY tiny percentage of the statistics.  It has most often been reported with labor induction and augmentation.  We hear a lot about this kind of rupture when we think of induction on a VBAC with cytotec.  

Find out if you have an anterior placenta (the placenta is on the front of your belly, near the old c/section scar).  An anterior placenta makes UR more dangerous and gives you only minutes to get to the operating room.

Do you have access to your OP reports from previous c/sections?  Do you know how you were sewn up?  Double sutures don’t matter quite as much as whether the OB took time and care sewing you up.

No one can promise you any specific outcome.  You have to be willing to be accountable for the risk of either VBAC or RCS.  No choice is 100% risk free…but statistically you are MUCH safer having a VBAC than you are having a 3rd c/section.

I will promise you that if you are not able to let go of the fear and apprehension, you will sabotage your ability to labor and give birth.  Please find a way to move past your fear.  I highly recommend a great childbirth class, yoga classes, stellar diet (to build strong, healthy muscle tissue), seeing a Webster-certified chiropractor (to make sure that everything is lined up correctly and prevent obstructed labor and decrease the risk of rupture) Make sure your chiropractor can come and adjust you during labor to help things move along or keep them going. is the most amazing resource for getting and keeping baby in a good position so that you aren’t ‘stuck’ in labor.

Do everything within your power to have an uneventful labor and your risk of rupture goes down.  Belly breathing was HUGE for me in labor and I believe it made the difference between success and failure for me. 

Ultimately, you have to be willing to accept the risk of getting your baby out, one way or another.  Build yourself up and be positive if you go through with labor.  Read positive affirmations daily out loud. 


ob said...

Ms Ryan,
If you don't know me let me first explain that I am a huge fan of both VBACs and you. However, with this post I have some problems. I appreciate the facts and for the most part they coincide with the reality I have experienced but not necessarily the "research" that I have read. This difference is too small to matter. But, to say there is some mechanism contained within the uterus to slow labor with a dehisience or that a baby can signal to its mother there is distress is just not correct. It borders on the nonsense of that idiot republican talking about rape and pregnancy. The uterus is a muscle and with a dehisince senses nothing. With a true rupture it invariably goes teutonic and hurts like hell, even through an epidural. Also, if a window is present once, I have always seen it present the next time. And before Abbey chews on me let me proffer that I have 24 years of practice and around 10,000deliviers performed or assisted (meaning I was just there to assist a natural birth - I am not arrogant enough to say I performed a natural birth). Additionally, I have assisted in around 2,000 sections. I do not hold myself out as an expert on anything and I do not "research," but I do have a wealth of observations. Just trying to be helpful not combative.

~Fort Worth Doula said...

Dear Ob, Thank you for your comment and I am actually honored to have you reading my post. (I am a fan of yours!)

This was thrown together as a response to a question, an email and I should have known better than to toss it up without editing/rereading.

You are correct, when dehisince is found the mother does not feel it, the uterus carries on in labor and will never know it was there unless a c/s is performed (So what's the point in worrying about it?) And I said that a true rupture would be very painful, and very scary.

When I refer to labor slowing for a distressed baby...This is something that I have witnessed...for example the uterus will only contract enough to get the job done but introduce augmenting drugs and then your risk of having a baby in distress goes up tremendously. Mom goes to c/section either because of a labor stall or baby stressed out with pit, then you find baby tangled up in a cord or with a partial abruption or some other issue. Many VBAC moms report their VBAC to be a 'longer, more gentle labor". Perhaps it's all coincidence, but maybe not. This is also one theory behind 'laboring down' and the 9-10 cm stall. It's a protective mechanism to give baby lots of blood and oxygen before moving through the birth canal. (I know that this isn't the case all the time but it's interesting when something like that happens and maybe I am totally full of crap, but nonetheless, I find these stories really interesting.)

Anyway, my whole point is...In order to VBAC, you need to be able to trust your body AND your provider, to believe that what you are doing is not going to kill both of you. The emotional baggage that women carry to their VBACs is suicide. Everything they read and hear make them think they are going to blow out their uterus. Again, I don't speak in absolutes, there is always risk in everything you do, Look at the statistics, figure out what you are comfortable with and go for it. Worrying will only harm you in the long run and it won't change whether you rupture or not. You cannot labor in constant fear.

Thirty Little Piggies Designs said...

My question is, does dehiscence lead to rupture? Is it a precursor, or is it a different condition altogether? I have asked many, including OB's, and have never been given a real answer. I have found no research either.

~Fort Worth Doula said...

Oh Thirty Piggies! That's the real questions isn't it? The only thing that we know is that we don't know! How common is dehiscence? The only way to know is to look inside every woman who ever had a VBAC. I've heard that in some places with certian providers, they will feel the inside of your uterus after a VBAC to see if there was a separation. Doesn't sound fun, does it? If the VBAC went well and there were no complications, then we are led to believe that the dehiscence is harmless. Mothers won't feel it, you won't know it's there unless you open the mom up. I suspect that mothers VBAC with 'windows' more often than we think. What bothers me is that dehiscence is included in the medical definition and statistics referring to rupture. It's all considered the same thing...however, common sense tells us there is a major difference between a weak spot in the uterine wall and a complete break in the uterine wall. You can look with ultrasound to see how thin the uterine wall is prior to delivery, but those found to be very thin will be counseled to have a RCS because we are inclined to believe that it is a precursor to true rupture.

It says all over the internet "The uterine rupture rate in VBACs is about or less than 1%". When people read that, not knowing the difference between dehisince and true rupture. They believe that no matter what, a "rupture" will end in death for either the mother or baby... again, not true. Even with a true rupture, the baby and mother can be safely delivered. ((I'm not in any way downplaying the seriousness of a true rupture. But depending on the situation, location of placenta, etc. the time you have to get to the OR varies. Either way, you don't want to experience a true rupture.))

(My OB told me about a VBA2C mom who came in to him and the baby had literally punched an arm out of the mother's uterus into the abdominal cavity. Baby and mom went to the OR and both were fine.)

I also suspect that there will never be a clear picture because when a woman has a section with a window, then RCS is the recommendation for subsequent births. It will be viewed as a precursor even though we truly don't know.

ob said...

I have seen thin walls deliver fine and thick walls rupture. I have performed post partum scar exams and on two occasions found no palpable anterior wall despite a perfectly normal delivery. All this to say statistics do not apply to individual deliveries in the real world. Ok, I will quit hi-jacking Donna's board. Oh, I have posted multiple times on this subject and even talked once about an entire anterior wall disruption (4/29/2012). I had hoped all the scare-masters would have been beaten back.

Thirty Little Piggies Designs said...

Thank you for the responses about dehiscence. I thought I would include a great link that helps one understand the difference between rupture and dehiscence. And supports what Fort Worth Doula said about the consequences of a true rupture.

Cassidy Cay said...

Thanks for posting this. I had a c-section last March after pushing for four hours at the birth center and hospital (3 at the center and 1 at the hospital) and am trying to glean any information I can to combat all the VBAC nay-sayers around me.

Seeing someone pragmatically compare the risks of a VBAC and the risks of another c-section is welcome to this mother's mind!