In every VBAC forum, in every Wise Hippo Birthing Programme for VBAC Mothers Class I teach, in every conversation I have with a mother who has previously had a caesarean it’s only a matter of time before the talk turns to uterine rupture. It’s THE risk most prevalent in our minds when we think about our births. But is all we hear about uterine rupture true and is there any good news when we’re talking about the risk of our uteruses exploding? (Sorry I deal with my anxiety with humour and this is how I coped when I thought of uterine rupture when planning my VBAC, you maybe more sensible).
1. There is only one type of problem that can happen with your scar and it’s a uterine rupture.
Uterine rupture is a serious event, which can be fatal for mum and baby. However this is not to be mixed up with scar dehiscence. This is when your scar comes apart, sometimes quite cleanly at an edge, and generally poses little risk – and sometimes is not noticed until an EMCS is performed for another reason. So when people talk about uterine rupture we need to be careful that we are not talking about scar dehiscence and making it seem more prevalent then it is. Equally a sensation in our scar, though not to be ignored, needn’t send us into panic mode. It’s not a matter of no feeling or uterine rupture. There is some middle ground.
2. Uterine rupture is the main risk of a VBAC.
There are a variety of risks for a mother birthing after a caesarean. There are many risks for any birthing mother. There are also many risks in life. There is simply no getting away from that fact. Conditions such as placenta accrete (where the placenta grows into the lining of the uterus or into the scar tissue) and placenta praevia (where your placenta grows to cover completely or partially cover your cervix) have risks which increase after a caesarean. Why is that a good thing? Well in many ways it’s not, but you may not have been aware of these risks or even been told about them, which I think illustrates how the risk of uterine rupture is not simply a risk label of 0.5%. Often this makes up 60% of the conversation we have with a doctor about our birth that is going to have a bigger influence on our fear.
3. That continuous fetal monitoring is the only way to detect uterine rupture.
A lot of hospitals will recommend continuous fetal monitoring. A lot of women worry that they will be confined to the bed and therefore will have a long painful labour, or that this will lead to a cascade of interventions (fears that are often justified). Continuous fetal monitoring is one method of detecting a uterine rupture. There are many others which entail having an observant and experienced midwife. Mary Cronk has some interesting views on how to spot some of the early signs of uterine rupture (read in full here) including mothers feeling and becoming familiar with their scars before birth. So that during birth the mother will be able to feel for any changes. Ultimately when making a decision about fetal monitoring or not, ask if you can move around (before and at the time) the doctor or midwife may presume you’re comfortable until you ask to move. A lot of units now have long wired monitors, wireless monitors and now even waterproof monitors for water births, and the midwife can always use a handheld monitor. So research, talk to your provider and remember you can adapt your plan at the time (though if you are comparing birth places their policies and reaction to your questions and concerns around monitoring maybe a good way to find the match for you).
4. That the uterine rupture rate of 0.5% is a static figure.
Actually there are many reasons why you are more or less likely to have a uterine rupture. If you have had a previous vaginal birth after caesarean you have a lower uterine rupture rate. If you have a twin pregnancy after caesarean you have a higher rate. Personal circumstances do make a difference.
5. That uterine rupture is very likely.
This is a matter of perspective. Firstly uterine rupture is a risk of a VBAC. Your midwife and doctor will need to work in a way which makes you and your baby as safe as possible. Hospitals and birth centres implement procedures and clinical pathways to standardise the care for VBAC mothers to make the care safer. However during all this talk of risk, within this post and outside, it’s easy to lose sight of an important figure. You are 99.05% likely to not have a uterine rupture. That’s a pretty cool number. To put side by side with another risk we maybe familiar with is the fact that condoms are 98% effective. So condoms are ineffective for 2% of users. Yet many use condoms and do not expect to have them fail. I do not wish to trivialise the risk of uterine rupture. Rather I seek simply to put the same picture into different frames and see how it changes our perspective.
Ultimately all decisions we make in life are risks. Getting in the car today, our health and lifestyle choices. Birth feels bigger because we are holding (and definitely FEEL like we’re holding) our little person’s life in our hands with every decision. This is a scary, unsteady hand sort of place to make a decision from. It therefore maybe helpful to focus on what we do want and dealing with the fear so we can plan and prepare for the birth we want and make decisions from an objective place (not a feels like I’m dropping off a cliff place).
I’m going to leave you with a quote from Jenny Lesley the writer of AIMS: Birth After Caesarean (which you should buy from here btw) who sums it up just perfectly.
“It may help you to focus on the fact that the risks of VBAC are small and that research only looks at trends and general outcomes. Your decision will be a personal one for this pregnancy, this baby, this time for you.”