Uterine Rupture

I think the negativity and shroud waving is not helping women to make the decisions that are right for them, and I firmly believe that care providers who deny women choices and options are the ones who should be struck off, not those who help women to do what feels right for them. Our health care system is in such a mess and so many women are getting truly awful maternity care not because women or babies need it but because care providers are frightened of lawyers.

It is not reasonable to pretend that it is a choice between mother and baby or life and death. A woman’s ‘experience’ or her baby’s ‘life’ because the two are inextricably linked. Mothers do not willingly and knowingly put their babies at risk, but each will make a different decision based on too many factors to say what is ‘right’ because, what ever happens, the woman carries the burden and not those who cared for her or steered her decisions. For that reason it can only be the woman’s choice what is done to her body and she has to take ownership of that choice and be comfortable with it.

Care providers are so filled with fear, and that fear is affecting the women they care for, in attitude and in denial of choice. A section rate of one in three is indefensible, and at that rate is causing MUCH more harm than good.  It always strikes me as staggering that women are talked out of a VBAC by clinicians presenting the statistic that VBAC carries a 0.5% chance of rupture, and yet women who are being encouraged to accept induction are rarely told that induction carries the same 0.5% chance of creating a hole in their uterus.

It may well be that the risks of VBAC and PAR are actually MUCH lower than women are being told, and the article Uterine rupture is rarer than previously thought by Professor Marian Knight of UKOSS (UK Obstetric Surveillance System), published by NPEU (National Perinatal Epidemiology Unit, University of Oxford), would appear to back that up. If women are really re-rupturing at the rates often quoted then their ruptures are not being repaired properly.  True ruptures are rare, catastrophic ones even more so  Often the term ‘rupture’ is used to describe benign scar separations, dihesences and windows, which aren’t a risky thing for mothers or their babies, and women are left confused by what they have been told about the state of their scar or uterus.  The book Silent Knife is really a very good read for stats, descriptions and discussions of pregnancy after caesarean surgery.

So often when women are being told of the risks of VBAC uterine rupture is presented as a grave danger.  However, women are rarely told that the risk of losing their baby to amniocentesis is three times greater, and they are rarely, if ever, told about the dangers associated with repeat caesarean surgeries.  That includes the very real and present risk of problems with placental attachment.  If you want to read more about this, the great resource Science and Sensibility has done a good job of covering placenta accreta it here.

There is good research to say that tears heal better than cuts (http://www.ncbi.nlm.nih.gov/pubmed/10422908) and so a repaired simple rupture (no healed edges to the hole, no placenta involved) should be stronger than a second planned section scar from an incision by knife.  This is clearly being taken on board, because many surgeons are now using ‘blunt extension’ techniques, which in effect means separating the uterine muscle by tearing it along its natural planes, which leads to a stronger repair and less trauma to the tissue.

I was told that a re-rupture was a certainty because my uterus would never stretch round a baby… Clearly that was a crystal-ball prediction, because it did just that and we were considerably healthier in my PAR than after either of my caesareans. That in itself has enormous benefits for the whole family!

I’m expecting that most of the re-ruptures are women who have had windows and scars that have opened during the trauma of a repeat section. We don’t worry about any other scar or injury to the same extent. I think that the ‘dead baby card‘ is just out-and-out blackmail. So few women carry a PAR (because most get a hysterectomy and the rest are told not to try again, of which a significant majority will heed that advice) that we will never have big enough studies to know what the numbers really look like.

I have been told repeatedly that no one has a baby after a rupture, well clearly I did, and I know others who have, yet it does not stop medics from telling woman that their experience is a universal truth, it isn’t, any more than mine is.  Women do have babies after uterine ruptures, yet many are told that it simply isn’t possible.

It is so wrong to tell women that if their babies die it will be their fault and that surgery will save everyone, because it doesn’t and it won’t.  Women have to make the choice that is right for them, it is their body, only they can decide…

If you want to read other thoughts on VBAC and rupture, have a look at birthing beautiful, there are some really good references!