The following article was originally written for 'Midwifery Matters', the Journal of the Association for Radical Midwives, after we had been invited to speak at their AGM in 1997. We believe it has stood the test of time well.
We felt very honoured to be asked to speak at the AGM of your organisation. To us, ARM is synonymous with good, supportive midwifery. Since our area of expertise lies in the mother's perspective and our contact with the midwifery profession is limited, we decided to give a brief talk on a subject known to us well, both from personal experience and from background reading. This was followed by open discussion.
Our interest in caesareans began with Gina's emergency epidural section for a breech presentation and Debbie's three emergency caesareans under epidural anaesthesia. We both felt the need to come to terms with our experiences and have gained information and insight from reading and discussion and from sharing our knowledge with other parents. Gina's second child was born at home as planned and Debbie's fourth child was a home water birth.
In 1994 the position of Caesarean Birth/VBAC co-ordinator for the NCT became vacant and we decided to take the post jointly, along with a third colleague. One of our major tasks has been writing a new NCT booklet entitled Caesarean Birth - Your questions answered which was published by the National Childbirth Trust in October last year. This booklet, which includes research evidence, practical tips and parents' experiences, will be helpful for many pregnant women and their partners.
A lively discussion followed our brief introduction and it quickly became obvious that the main area where information was lacking was that of caesarean scar rupture. Many questions were raised on this topic and since we were asked if we would submit an article to Midwifery Matters it was an obvious choice.
The belief that vaginal birth after caesarean (VBAC) is dangerous owing to the risk of scar rupture is common, both among the general public and among those working in the maternity professions. Indeed an article in a national newspaper quoted the response of one obstetrician to a woman's request for VBAC was: 'That's alright Pam. Everyone has the right to die in the way they choose but I just don't want to be around at the time, and I'd rather it didn't take place in my hospital.' Not surprisingly the mother opted for an elective repeat section (The Times, 1996).
Sadly, this is not an isolated incident. It is common. Women are told they will die, their baby will die, or they will require hysterectomy when, rather than if, their caesarean scar ruptures during a VBAC. We want to take a closer look at these possible outcomes.
The most commonly quoted scar rupture for LSCS, especially by those opposed to and afraid of VBAC is 0.5%, or one in 200 (Murray, Enkin and Chalmers, 1994). We have been unable to obtain statistics concerning scar rupture in this country, but if one in every 200 VBAC labours had such serious consequences for the mother or baby, surely we would all be hearing about individual cases?
There are no statistics generally available concerning the numbers of VBAC labours in Britain. Although VBAC studies show 'successful vaginal delivery' rates of around 80% can be achieved, actual hospital statistics for VBAC labours are generally considerably lower since a great many mothers are not given the opportunity and necessary support and encouragement to labour. Even so, substantial numbers of VBAC labours take place in this country every year and most midwives will not encounter a scar rupture during their career.
There are other severe problems that can arise during labour in all women. These include:
All pregnancies carry risks. However, although VBAC mothers maybe at a very small additional risk it seems invidious to single out the risk of scar rupture for special attention. We are not suggesting for one moment that scar rupture should not be mentioned, but information needs to be given out in a balanced way which does not disempower women or midwives.
The scar rupture rate of 0.5% includes even slight dehiscences or 'windows' which carry no adverse sequelae. However, what mothers often understand by this much quoted statistic is that they have a one in 200 chance of losing their baby, their uterus or even their own life.
On rare occasions babies do die as a result of caesarean scar rupture. However, as we have seen from the statistics, it is a rare event and the risk is nowhere near the 0.5% that is so often implied.
The International Childbirth Education Association (JCEA) published a review, 'Vaginal birth after caesarean' in August 1990 (Sufrin-Disler, 1990). It reviewed current medical and scientific literature concerning VBAC and concluded:
In over 21,000 planned labors after cesarean, five babies were reported to have died in association with scar rupture (0.02%).
These figures include VBAC research from around the world. If only data from industrialised countries are considered, in over 17,000 planned labors after cesarean two babies have died in association with scar rupture(0.01%).
In a review of the medical journals during the 35-year period 1950-1985, Bruce Flamm found reports of two fetal deaths per 10,000 (0.02%) owing to low transverse uterine rupture (Flamm, 1990). Since the most recent and lowest perinatal mortality rate for England and Wales is 6.1 per thousand, VBAC mothers are not at a significantly higher risk of losing a baby than any other women. A mother is therefore 30 times more likely to lose her baby from some other cause.
Despite evidence to the contrary, mothers continue to receive the impression that every scar rupture ends in the death of the baby, and that one in 200 VBAC babies dies from this cause.
Quoting from the same ICEA review concerning the risk of hysterectomy:
Twelve mothers lost their uterus due to scar rupture during these 21,000 planned labors after cesarean (0.06%). This is less than one tenth of the 0.7% hysterectomy rate reported for 'obstetric hemorrhage' after cesarean section (Clark et al, 1984).
Thus mothers who opt for a repeat section have a greater risk of losing their uterus.
Regarding maternal mortality, the ICEA VBAC Review concludes:
There has been no report of a mother who has died due to rupture of a cesarean scar during planned labor after cesarean. In contrast, reports continue to document deaths of women due to complications of elective repeat cesarean operations.
Therefore it is unreasonable that mothers should continue to be threatened with this risk. Despite the wealth of evidence showing that serious wound dehiscence is a rare complication during labour after previous caesarean section, the safety of VBAC continues to be called into question and mothers continue to opt for elective repeat section in the mistaken belief that this is safer than the risk of labouring with a scarred uterus (Murray, Enkin and Chalmers, 1994).
Having established that the risks of scar rupture are low, and in most cases lower, than the risks of elective repeat caesarean section, we must nonetheless acknowledge that scar ruptures do occasionally occur with tragic results. When a baby dies the statistics are totally irrelevant to the mother. It doesn't matter to her (or the midwife concerned) whether she is one in 200 or one in two billion.
There are no available British statistics on serious scar rupture. We don't know how many there are; their whereabouts or their circumstances. We don't know why scars rupture. In the rare instance that a true rupture of a caesarean scar does occur with serious consequences, the general reaction tends to be dismissive, a shrugging of shoulders and an acceptance that this is the risk taken with VBAC.
There seems to be secrecy surrounding cases of scar rupture. Often this is explained away by patient confidentiality, possibly because it is such a rare occurrence that everyone would know who was being discussed. However, confidentiality should not mean concealing valuable information and preventing discussion of the circumstances. Without this openness we will continue to be unsure about any warning signs and be less able to take steps to reduce the risks of serious consequences in any future cases.
Despite the lack of literature on the subject of poor outcome following caesarean scar rupture, a picture is beginning to emerge. Following an article published by The Association for Improvements in the Maternity Services (AIMS) we have been able to formulate what we think of as a recipe for a scar rupture disaster.
Although we have a list of ingredients, we have no quantities. However, we feel that a detailed discussion around the lack of knowledge in itself, can give those of us with a deeper understanding of normal birth a measure of confidence and much optimism since we do not believe that normal, healthy, naturally labouring women are at risk of scar rupture.
Each ingredient of the recipe can provide a detailed area for discussion.
When a rupture takes place in a woman who has had a previous caesarean can we always be sure that it is the caesarean scar itself which has ruptured? It may be that on occasion this is simply assumed. It has been noted in the literature that often it is not possible to see a caesarean scar on the uterus with the naked eye (Francome and Savage, 1993). There needs to be clear differentiation between caesarean scar rupture and rupture of non-scarred uterine tissue. Clear, detailed information needs to be available on all ruptures.
Issues such as rate of recovery from the caesarean, whether there was infection, the type of infection and how well it responded to treatment are among the areas where information is not collated and therefore cannot be connected to VBAC outcomes.
We understand that prostaglandin gel pessaries have only been in common use since the 1980s. Therefore most of the scar rupture statistics predate their use. It has become obvious to us that some obstetricians are aware of the possible dangers of using prostaglandin gel on women with scarred uteri. Others do not appear to know that while prostaglandins induce labour by dissolving the collagen network at the unripe cervix, they may also dissolve any collagen scar tissue at the site of a previous section thus leading to rupture (Kelly, 1996).
Prostaglandins, once administered, cannot be controlled. More details are needed about the type, quantity, timings and physiological responses in order to know when they can be used with relative safety.
Following prostaglandin induction it is common practice to augment labour with an oxytocin drip. Again details are need on timings, rate of administration and physiological responses.
Older literature does question the use of oxytocin in women with scarred uteri, but this generally relates to studies performed before the advent of current technology which allows oxytocin to be administered in a very controlled way. Since oxytocin is known to have a short half-life, it may be possible to forestall a problem by simply turning off the drip. However, the safety of using both prostaglandin pessaries and oxytocin is still open to question.
We know that midwifery staffing levels are sometimes well below optimum. It is considered normal practice for a midwife to be caring for more than one woman on a labour ward and her level of experience should always be taken into account. Subtle messages may be given out by labouring women and there may also be other indications that all may not be quite normal; these may not be picked up even by an experienced midwife who is overloaded, or may not be noticed until it is too late. In order for midwives to give optimal levels of care and ensure safety for all labouring mothers, we need a system where one midwife cares solely for one labouring mother whom she knows well. (Just what the One Mother, One Midwife campaign is currently calling to be made available for every mother who want it.)
Women labouring at home are generally aware that they must take responsibility for their own safety. However, often when a woman labours in hospital she has handed that responsibility over. Therefore a woman labouring with minimal attention labours under a false sense of security.
We suspect that in serious cases of rupture the earliest signs will often have been missed. It is important that such signs are discussed with the benefit of hindsight so that other midwives and other mothers can learn about them.
From our discussions with a very small number of women who have suffered a rupture, there seem to have been warning signs, including a feeling of unease and even distress in the mother. The authors find it difficult to believe that a woman who is in touch with her instincts will be totally unaware of such a major impending event within her body. The mother may not of course accord any importance to such feelings at the time, and indeed medical staff may reassure her too effectively, leaving the warning signs ignored. If this is happening, we all need to be aware of it.
We know of one case where a mother booked for a home VBAC transferred into hospital purely on instinct. During the ensuing emergency caesarean section for genuine fetal distress a rupture occurred up the rear uterine wall. The baby was fine and the uterus repaired. In other cases when early warning signs were missed and mothers falsely reassured the outcome was not so good. We are also aware that on occasions a midwife may have felt something was not right but had difficulty getting a doctor to take her seriously.
Finally, when a rupture occurs we need to know what led to the diagnosis, by whom it was made, what actions were taken, how quickly, and the outcome.
It is not known how quickly a rupture must be dealt with in order to minimise the risks to mother and baby, and how much variation there may be in this. When a baby dies, any avoidable delays in getting the mother to the theatre may be relevant.
It is not enough simply to accept the occasional fetal death owed to rupture as inevitable. It is likely that there will be reasons that can account for scar rupture and poor outcome.
Admittedly, the foregoing discussion is unlikely to bring much peace of mind to those midwives who find themselves taking care of several women, all of whom are well on the road to a technological birth. However, we hope this article will give heart to those endeavouring to practise true midwifery.
One of the criticisms often levelled at maternity professionals is that they do not see the long-term consequences of their actions and of various forms of care, especially caesarean section. Neither do midwives and doctors see the long-term benefits that excellent midwifery can have for the mother, baby and the whole family. A good birth experience can have a wonderfully positive effect upon a woman's everyday life, her relationships with her baby, her family and others, her personal level of confidence, and her ability to cope with the trials of life in general.
Few mothers realise how good midwifery care can optimise their birth experience, and even fewer know about the far reaching effects this will have on their future life. If and when they do, they are usually no longer in contact with the midwife and cannot express their gratitude.
On behalf of all VBAC mothers now and in the future, 'Thank you'. We need midwives who will be 'with women' and all your efforts, no matter how small and inadequate they may seem to you, are very much welcomed, needed and appreciated by mothers, especially those who want a VBAC.
Debbie Chippington-Derrick and Gina Lowdon
First Published in the 'Association of Radical midwives' journal 'Midwifery Matters' pp18-21 Issue 73 Summer 1997