American College
of Community Midwives
A professional organization for Community Midwives

Relative Risks in Childbearing

Article on VBAC risks from Australia
http://www.birthrites.edsite.com.au/uterinerupt.html

The key thing in deciding what sort of birth you want to have is to make a conscious decision of the risk YOU are willing to take. To put this into perspective lets look at some comparative risks.

·         Risk of a healthy woman having 7 or more medical/surgical interventions during labor and delivery if giving birth in an American hospital is 93%        or         <<1 in 1

·         Risk of delivering by cesarean in a California hospital is 27.6%    or         >>1 in 4
Note: box for USA /California stats was not part of original article as published on web site,

·           Statistical References: CDC 2003;“Listening to Mothers” survey, Maternity Center Association, 2002

Original article ~ Statistics from world literature, primarily published in USA and UK

· Risk of being diagnosed with dystocia (baby too big) is: 10 - 12% = 1 in 10

· Risk of a breech baby at full term is: 3 - 7% = 1 in 33

· Risk of your baby being diagnosed with fetal distress in labor: 2% = 1 in 50

· Risk of baby dying in a vaginal breech birth is: 1 - 4% = 1 in 100

· Risk of dehiscence or rupture / horizontal LSCS scar / TOL is: 1% = 1 in 100

· Risk of having twins is : 0.4% = 4 in 1000 births or 1 in 250

· Risk of your baby developing cerebral palsy in any birth is: 0.25% = or 1 in 400

· Risk of your baby dying during any VBAC delivery is : 0.2% = 1 in 500

· Risk of your baby dying during any type of delivery is: 0.12% = >>1 in 1,000

· Risk of your baby dying from a rupture of the uterus is: 0.095% = 1 in 1,000

· Risk of dying during any cesarean section is: 0.04% = 1 in 2,500

· Risk of dying during an elective repeat cesarean section: 0.0184% = 1 in 5,000

· Risk of dying from a rupture of the uterus is: 0.0095% = 1 in 10,000

· Risk of dying during any vaginal delivery is: 0.0098% = 9.8 or 1 in 10,000

· Risk of dying during an uncomplicated vaginal delivery 0.0049% = 1 in 20,000

The likelihood of a fatal outcome from a uterine rupture is no higher than the general incidence of death in all births and is lower than that for cesarean births.

Of 873 fetal deaths in the UK during 1994 - 95, 42 (4.8%) were due to uterine rupture, 30 of these were in mothers with a CS scar and 12 were in unscarred uterus. (ref 5)

As you can see the risk of you or your baby dying from a uterine rupture is no higher and in some cases lower than it is from 'normal' or cesarean delivery.

All births have some degree of risk even if you have a perfect history, the key thing is to identify what you consider too great a risk and then take actions so that you can receive the best possible care if your worse case happens. The big thing to remember when putting this in perspective is that sometimes (thankfully rarely in western countries) mothers and babies die both at hospital and in home births.

There are risks of being in hospital (such as the higher chance of intervention and infection) and risks with being at home (such as longer time to get to a place where you can receive emergency resuscitative procedures). It is up to you where you think you will be safer, and what sort of labor you think will be safer (i.e. with or without interventions). From the statistics you can see that any doctor that tells you that a certain way is risk free is lying. The only risk free way to have a baby is to adopt.

The best thing you can do if the risks really worry you is to ensure you are in an environment where if a rupture does occur it can be promptly dealt with. This environment would usually be a hospital or a birthing centre.

If you are in hospital you may ask for intermittent or continuous monitoring, which is the most reliable (but not 100% accurate) in the indication of a possible rupture. Monitoring can also be done during birthing centre and home births but it is usually intermittent with a stethoscope for fetal Doppler.

Other actions such as epidurals and drips will not make an emergency caesarean any quicker. An emergency caesarean from a rupture would normally be done under a general anesthetic anyway, and a drip can be put into a person in a couple of minutes or less.

========Paper written in the United Kingdom============

References

· Peripartum haemorrhage by Dr Sanjay Datta, MD, FFARCS

· Common Peripartum Emergencies by Dr Elizabeth Morrison American Family Physician Journal Nov 1 1998

· Once a CS always a Controversy by Dr B L Flamm ACOG Journal Vol 90 No2 Aug 97

· The Risks of Lowering the Caesarean Delivery Rate by Dr B Sachs MB, BS, DPH, Dr C Kobelin, MD, Dr Mary Ames Castro, MD and Dr Fredric Frigoletto, MD, The New England Journal of Medicine, 7 Jan 1999, Vol 340 No.1

· Induction of Labour and Uterine Rupture by Dr R Foon SHO, CESDI Steering Group 5th annual report 1997: 63-71

· Vaginal delivery after previous csec remain relatively safe by Dr Gregory and Dr L Korst, MD and Dr P Cane PhD Obstetrics and Gynaecology 94(6), Dec 99 pp 985-989

· Coombe Women's Hospital Obstetric Report 1998

· Genital Tract Trauma and Other Direct Deaths: Annual Report of The Maternal and Child Health Research Consortium London Jul 1998.

· Will VBAC become a way of the past OBCNEWS Issue 15.3, 13 Jul 1999

· ICAN /VBAC / Caesarean Webpage

· Recognising Problems in Labour by T. Stevens (Midwifery Research Practitioner)

· VBAC - Vaginal Birth After Caesarean or Very Big Authority Challenge? by B. Beech and P Thomas, AIMS Journal, Vol 8 No. 1 30 Apr 96

· Cases of Uterine Rupture and Subsequent Pregnancy Outcome by Al Sakka, Dauleh and Al Hassani of the Hamad Medical Corporation. International Journal of Fertility & Womens Medicine Nov-Dec 99.

· Delivery after Scarred Uterus at the University Hospital Centre of Dakar by Cisse, Ewagnignon, Terolbe and Diadhiou Journal de Gynecologie, Oct 99

· Vaginal Birth after Caesarean and Uterine Rupture Rates in California by Gregory, Korst, Cane, Platt and Kahn. Obstetrics & Gynochology Dec 99

· Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions by Shipp, Zelop, Repke, Cohen, Caughey and Lieberman. Obstetrics & Gynecology Nov 99.

· Rupture of the pregnant uterus a 21 year review - Sakka, Hamsho and Khan. International Journal of Gynaecology & Obstetrics Nov 98

· Vaginal Birth after Caesarean results in 310 pregnancies by Obara, Minakami, Koike, Takamizawa, Matsubara and Sato. Journal of Obstetrics & Gynaecology Research Apr 98.

· Intrapartum rupture of the unscarred uterus by Miller, Goodwin, Gherman and Paul. Obstetrics and Gynecology May 97.

· Risk Factors Associated with Uterine Rupture during TOL after CSEC by Leung, Farmer, Leung, Medearis and Paul. American Journal of Obstetrics and Gyynecology May 93

· Rupture of low transverse csec scars duritng trial of labour. THe Journal of the American Medical Association 18 Sep 91

· Use of Hospital Discharge Data Monitor Uterine Rupture - Massachusetts 1990 - 97. Morbidity and Mortality Weekly Report 31 Mar 2000

· Use of Prostaglandins to induce labour in women with Csec scar by Vause and Macintosh. British Medical Journal Apr 17 1999.

· Csec Scar dehiscence following vaginal delivery by Connoly and Byrne. Journal of Obstetrics and Gynaecology Vol 19 No 6 1999

· Trial of Labour after Csec by McMahon, Luther, Bowes and Olshan. New England Journal of Medicine 1996.

· Catastrophic Uterine Rupture: Maternal and Fetal Characteristics by Kirkendall, Jauregui, Kim and Phelan. Obstetrics and Gynecology 2000

· Uterine Rupture: A placentally Mediated Event? by Jauregui, Kirkendall, Ahn and Phelan. Obstetrics and Gynecology 2000

· Uterine Rupture During a Failed Trial of Labor: Are There Any Identifiable Risk Factors in Labor Management by Burke, Lee, Harish, Sehdev and Ludmir. Obstetrics and Gynecology 2000

· Vaginal Birth After Prior Cesarean by Dr C Brittan. Jul 99.

· Delivery After Previous Csec: A Risk Evaluation by J Rageth. Obstetrics and Gynecology 1999.

· Medical Abortion Complications by D Nemec Obsterics and Gynecology Apr 78

· Cesarean Section: Guidelines for Appropriate Utilization by Dr B Flamm and Dr E Quilligan

· Risk of a healthy woman having 7 or more medical/surgical interventions during labor and delivery if giving birth in an American hospital is 93% or <<1 in 1

· Risk of delivering by cesarean in a California hospital is 27.6% or >>1 in 4 Note: box for USA /California stats was not part of original article as published on web site,

· Statistical References: CDC 2003;“Listening to Mothers” survey, Maternity Center Association, 2002