Uterine rupture questions

[Maman1234]

I've heard about the risk of uterine rupture during vbac but I've also heard that uterine rupture is not always an emergency situation and it's rare for the baby and mother to be at serious risk from it. I've also heard that uterine rupture can lead to a hysterectomy to save the mother. Does anyone understand all these things? I'm wondering what would actually happen in case of a uterine rupture and how dangerous it would be? What are the signs of uterine rupture to look out for? Does it only happen at the pushing stage or could it happen earlier? If it could happen earlier then do vbac women have to go to hospital earlier? The stuff I've read about this is very confusing!

Hi can only give a response based in personal experience (i have been a midwife for nearly 19 years). In my opinion there is absolutely no way that a ruptured uterus is not an emergency. For a mum it can cause neurogenic and hypovolaemic shock (seen both of these) which in turn compromise baby. I have seen extremely poor outcomes (for mum and baby) from uterine rupture which can happen at anytime of labour. The signs are scar pain, shock (raised purse, low BP) vaginal bleeding and fetal distress. It is hard to generalise as they can present differently. I am aware that my experiences have clouded my judgement but I can balance that by having seen many vbacs too.

What would be the best thing to do then for vbac? Can you stay at home in labour until you need pain relief but look out for any signs of rupture? Or do you have to go into hospital early? When you say poor outcomes what sort of thing are we talking? Are there any stats on injuries caused by uterine rupture and how frequent they are?

I'm considering a vbac but I think I would really need to understand the risks and how to do it safely. Otherwise I will go for elcs.

Are you possibly confusing dehiscence and rupture?

Your consultant will be the best person to talk to as they'll have be able to assess the risks against your specifics. The general statistic is 1 in 200 for rupture and unfortunately yes, poor outcomes can include one or both not surviving.

I'm intending on a VBAC in ~8 weeks and have been told to phone labour ward as soon as things start happening and they'll assess at that point depending on my symptoms.

I find this quite helpful: www.homebirth.org.uk/vbacur.htm

Also a lot of the newer research suggest risk of rupture in a previous cs to be 0.5-1/200-400

Do you have a link to the new research, Brionius? I'd be very interested to read it.

I have experienced full rupture of my urinary bladder and uterus during the latter stages of VBAC. I had been planning to have my section on a Monday but inadvertently went into labour the day before.

We were lucky as it went as I was being prepped in theatre and I already had an epidural in place. However I lost 6 units, had DIC as a result and because of this, I'd hesitate to recommend VBAC if you have any suggestion of disproportion with regards to baby size and pelvis.

I am aware that my experience is anecdotal and my advice must remain so of course. But you cannot remain at home and expect to get away with it if you rupture at home. Chances are you won't access help in time and by help I mean immediate emergency CS and "looking out for signs of rupture" is virtually useless because those signs aren't a 'warning', they are the real deal happening. You can get little warning of rupture, you see and no guarantees that you will know anything until it is too late. Full rupture is a catastrophic surgical emergency. There is little time to act and we only survived because the surgical reg basically plunged in and got the baby out. It took an hour to stabilise me.

If you are going to attempt VBAC, you really need to be in a birthing unit with acces to OR facilities. Rupture is rare but it is very dangerous.

Good luck (after my horror story ;))

Oh lordy. I've been told to try for a VBAC this time (am 32 weeks). This is despite having investigations of my c section scar which found it to be "defective" with a loss of over 50% of the uterine wall. My consultant knows this but said my risk level is the same as anyone else - 1/200. Gulp.

Worried - you're same gestation as me. I've been told by my consultant that she strongly advises continuous monitoring as it's the most reliable sign of anything going wrong (fine, I agree) and being on labour ward not MLU. Have you got an appointment coming up? Is it worth discussing further and pressing for more details re the investigation?

Hi Commander I had an appointment yesterday and this is what I was told (again) after I provided the report of the private gynae that investigated my scar (this was done last year as part of infertility investigations). The reason given was that they don't know that every woman's c section scar isn't the same as mine so there's no evidence to indicate my risk of rupture is higher.

I was told I would be carefully monitored and I was very very clear that although I'm prepared (reluctantly) to try VBAC I will want a section at the first sign of any trouble including fetal distress or lack of progress. What I definitely don't want is a repeat of last time which involved hours of back to back labour with no progress and very distressed baby and THEN an EMCS.

Sorry to hijack OP !

I had a VBAC. I wanted to give birth at the MLU (just downstairs from full on obstetric unit) and in order to do so they wanted to make sure I understood about rupture risk. As a PP said, it absolutely is a serious emergency, and the reason I ruled out a home birth. However, routine monitoring for a VBAC is usually fetal heart rate, which is not the best indicator of rupture. I firmly believe a good midwife is the best thing to have present - they will beat all the electronic monitoring IMO.

The risks are low but the stakes are high, unfortunately. That said I would not hesitate to have another VBAC.

Warning- description of effects of rupture, in case you are PG and wish to avoid.

My first indication was a low, deep pain underneath my scar which punched through my epidural.

The second indication was a large PV bleed.

Only then did the monitors start shouting and by then I was being opened up. The sussed straight away but FHM alone was of little use as a guide, in fact because my son was partially extruded through the rupture into my abdomen, we lost the trace anyway.

I'm sorry, I know this is all a bit graphic if you are PG. It IS very rare.

Worried and commander I'm 32 weeks as well and considering vbac
Very anxious about it though. Also have gestational diabetes so another complication to add into the mix! Because of this they have mentioned inducing me if baby seems to be large. I thought inductions were a terrible idea for a vbac due to relentless contractions and therefore increased risk of rupture... It's all so confusing.

What does PV stand for? And is FHM foetal heart monitor?

Oh god, I am sorry. Yes FHM is fetal heart monitor and PV is Latin for per vagina meaning a bleed via the vagina.

Induction was contraindicated when I had mine because of the previous scar, it can be placed under greater pressure.

Think about what you want to do. Ensure your team discuss things in terms that you understand- the evidence can sometimes be couched in very remote statistical terms which can mean less to a person.

The best outcome is a healthy baby and mother. How that happens can be flexible. There is no 'ideal' way morally and don't let anyone make you feel bad about choosing a CS.

Good luck!

I told my consultant that I would refuse induction so if I go overdue and elective section may be on the cards. He did say that a syntocinon drip is only one method of induction ( and I think the only one contraindicated where there's been a previous section) and he wanted me to think about whether I would be prepared to have a pessary or my waters broken. Erm. Not really no.

I was given a c-section last time, while trying for a VBAC, as I had pain concentrated in my scar (labour was also not progressing well either). The surgeon said afterwards that my scar wall had been very thin and that the section had been the right call, which was good to hear as I had wanted very much to have a natural delivery the second time. I agree that although trying for a VBAC is worthwhile (I know plenty that have been successful), being in a hospital is a good idea. I was in the birthing unit, then wheeled over to the normal labour ward as things weren't going well, and then into surgery when the scar pain increased. It was all calm though, and it was all much easier the second time as you know what a c-section involves. I was glad to have tried, and not too upset by failing as it was clearly the sensible thing to have a c-section under the circs. Rupture is absolutely a life threatening emergency, and although thankfully rare it is worth factoring in when choosing where to give birth after a prior CS.

It's so interesting reading this thread. Prior to being diagnosed with gestational diabetes I had been considering a home birth. My home birth midwife was very dismissive of my concerns about uterine rupture but her approach didn't remotely reassure me! It's actually been a relief having the location of the birth dictated to me. I just hope I go into labour naturally and avoid induction or cesarean although birth actually terrifies me! Gah
All so complicated.

A midwife shouldn't be so dismissive about anyone's fears. That in itself is a warning sign because reassuring someone about a rare complication is far removed from dismissing it.

Always trust your instincts- they are there for a good reason.

I've agreed to try a vbac this time but certain things the vbac midwife has said has given me cause for concern.
Firstly she said we advice all ladies to stay at home until they are between 3 to 4 cms. Which if fine if you don't have a scar and labour normally... But if your last c section was caused by lack of progress and foetal distress surely it is better to be in hospital. I had really strong contractions and never went past 4 cms. Am I really expected to stay at home with strong contractions?
Also my son showed signs of distress at this point so thank god I was actually in hospital. I know how unpleasant midwifes can be if they think you get to hospital too early.

iniquity sounds like we had a very similar experience last time. I went to hospital after having very strong contractions for 6 hours that were 90 seconds long and coming 3 in 10 . I was only 1cm dilated and they tried to send me home. I felt strongly (and as it turned out rightly) that something wasn't right so refused to leave the hospital. The midwife that saw me wrote in my notes that she heard a heart deceleration but still wanted me to go home. Anyway I was 'allowed' to stay and 4 hours later (during which time I wasn't monitored at all) I was 4 cm and in agony. As soon as I was put on continuous monitoring it was clear that the baby was very distressed. They still messed about for another 6 hours before I had an EMCS. By that point I was still only 4 cm and the oxygen level had dropped in DS's blood. I just wish I'd had the EMCS a lot earlier.

This time there is no way on earth I'm going to let it go on that long again. Any sign of distress or failure to progress I'll be making my feelings about an c section. I'll also be going to the hospital as soon as my contractions start!

I'm there with you worried mum. My priority is a living baby. I would rather have early monitoring even if it decreases chances of a vbac. From past experience I don't labour normally or well so the rules should be different.

I'm planning on going for a vbac following a c section 20 months ago, I'm due to give birth next month and I am now starting to get anxious and paranoid about my scar rupturing during labour.
I want to find out the scar thickness which may help alleviate some of my anxieties and help me make a more informed decision about the type of labour I should have.
Does anyone know how I can request a scar thickness diagnostic/ scan, if I do request it will the hospital organise this or are they like to refuse. I just feel it would really help having a scan done to check the thickness to help me stop myself from losing my mind