A vaginal birth after a C-section, called a VBAC, can be very risky. One of the most serious risks of VBAC is a ruptured uterus, which is a devastating event that occurs when the wall of the uterus (womb) tears open, potentially expelling the unborn baby into the mother’s abdomen. A rupture is life-threatening for both the mother and baby. A common cause of uterine rupture is the separation of a previous C-section scar, which typically occurs due to the forces and stresses of uterine contractions associated with attempted vaginal delivery.
Sometimes the scar can separate before labor from the stress of carrying a baby, especially if the baby is past the due date. This is what happened to a mother named Georgia, whose physicians urged her to attempt a VBAC, even though she had at least one significant risk factor for the procedure. She was at risk because she previously had a history of failing to tolerate labor, with her baby showing signs of distress. In her first pregnancy, Georgia was in labor for 34 hours and never dilated more than 6 centimeters. When her baby’s heart rate began to drop, her physician performed a C-section.
On the day before her baby was due, Georgia began to get nervous about the delivery and requested a C-section. She was told by her primary care physician that one could not be scheduled until the following week. The day after her due date, Georgia checked into the hospital with what she thought were labor pains. The OB-GYN confirmed that Georgia was not in labor and sent her home. She was instructed to return to the hospital when her labor pains got so bad she couldn’t talk. The next evening, Georgia was awakened with a slight burning sensation in her abdomen, a pain she described as being “off” and “not right.” She went back to the hospital, where the fetal monitor and ultrasound showed that her baby had no heartbeat. Georgia was later informed that the pain she had was actually her uterus separating, and that the burning feeling was most likely her uterus rupturing.
After her baby had been pronounced dead, Georgia’s physicians told her that they needed to induce labor to deliver the baby, and if the induction didn’t work, they would need to perform a C-section. When labor induction failed to work, Georgia demanded a C-section, but the nurses hesitated to wake the surgeon. Her husband further insisted, and the nurses finally agreed to call the surgeon.
After the procedure, Georgia was told the damage to her body was quite severe. Her uterus had fully ruptured and the baby had been in her abdominal cavity. Although her uterus had healed from her first C-section, the incision had fused against her bladder, which also was ruptured. Georgia had to have an additional “clean up” surgery, which revealed damage to her cervix as well. Several experts that reviewed her records told her that by all accounts, she should not have survived the ordeal. Georgia has since been told by a new set of physicians that had a C-section been performed prior to her due date, her baby would have survived. Her OB-GYN maintains that the baby’s death was due to the uterine rupture.
Georgia’s traumatic experience of losing her baby and almost dying herself was the result of physicians’ failure to notice and appreciate her signs of uterine rupture. Furthermore, she had a significant risk factor for VBAC, which made it imperative for her physicians to have a serious and thorough conversation with her regarding the risks and benefits of the procedure, as well as its alternative, which is delivery by C-section.
VBAC and Uterine Rupture
When any signs of uterine rupture are present, the mother and baby should be closely monitored, especially if the mother has any of the risk factors for uterine rupture. Monitoring the baby’s heart rate is crucial; often, a deterioration in heart rate is a leading sign of rupture. Georgia had at least one risk factor for uterine rupture. When she went to the hospital with pain the first time, Georgia and her baby should have been placed on continuous monitoring, with careful attention being paid to her baby’s heart rate.
Due to the potential for devastating consequences, it is critical for physicians to appreciate the risks for and signs of uterine rupture. In addition, a thorough discussion of the risks and benefits of a VBAC must be discussed with the mother. If conditions of the pregnancy change, thereby making a woman’s likelihood of success with a VBAC decrease, the mother must be informed so that she can revisit her decision to undergo the procedure.
Significant risk factors for VBAC include, among other things:
- History of failure to tolerate labor with fetal distress
- Maternal Obesity
- A single layer closure in a prior C-section
- Prior C-section delivery (within 14 months)
- Large for dates baby (large for gestational age, or LGA)
- African American race
Indeed, uterine rupture is a very serious risk associated with VBAC. Risk factors for uterine rupture include the following:
- Single layer closure in prior C-section
- Scarred uterus
- The use of Pitocin, Cytotec and other labor-inducing drugs
- Post-term labor
- Large for dates baby
- Multiple fetuses (twins, triplets, etc.)
- Fetal malposition (e.g., breech, face presentation)
- Maternal obesity
- History of failure to tolerate labor with fetal distress
- Labor dystocia (difficult labor), particularly at advanced gestation
- Low Bishop score on admission to Labor and Delivery (Also called the cervix score, this is a scoring system used to help predict whether induction of labor will be required/used to assess which women would be most likely to achieve a successful labor induction.)
- Previous uterine rupture
- African American race
- Trauma (gunshot wound, car accident)
- Obstetrical maneuvers, such as internal version (physician’s adjustment of baby’s position in the uterus by placing one hand in the mother’s vagina and the other on her abdomen) and extraction of a baby in breech presentation, as well as use of vacuum extractors and forceps.
If any of the signs of uterine rupture are present, a mother and baby must be closely monitored. If even one sign is present during labor, physicians must prepare for an urgent delivery, usually by C-section. Signs of a ruptured uterus include the following:
- Fetal heart rate abnormalities
- Sudden or worsening abdominal pain
- Decreasing uterine contractions
- Vaginal bleeding
- Hemodynamic instability
The classic signs of rupture, however, have been shown to be unreliable and frequently absent. Abnormal heart tracings and a slow heart rate seen with fetal heart rate monitoring are the most common and often the only manifestations of uterine rupture. In most cases, signs of fetal distress will appear before pain or bleeding. It is thus critical for physicians to monitor the mother and baby, and be ready to perform an emergency C-section if indicated. Furthermore, the time between diagnosis of a rupture and delivery should be less than 18 minutes in order to avoid damage to the baby. Brain damage can occur during a uterine rupture because the rupture often deprives or completely cuts off the baby’s oxygen supply.
Uterine Rupture Diagnosis and Medical Malpratice
It is imperative that close monitoring of a mother and baby occur near the time of and during delivery, especially if a mother has risk factors for uterine rupture. It is essential that physicians pay close attention to the fetal heart rate and be prepared for a quick delivery, usually by C-section. Failure to properly monitor the mother and baby and to notice signs of a rupture is negligence. Failure to follow standards of care and to quickly and properly deliver the baby also constitutes negligence. If this negligence leads to permanent injury in the baby, it is medical malpractice.
The nationally recognized lawyers at Reiter & Walsh ABC Law Centers have many years of experience in birth injury cases, including uterine rupture and VBAC cases. If you experienced any of these complications during pregnancy and your child developed an injury such as cerebral palsy or hypoxic ischemic encephalopathy (HIE), we can help you. Our skilled attorneys will work tirelessly to get you the compensation you and your family deserve. Call us at 888-419-2229 for a free consultation.