In this final article in a series on the topic, New York lawyer Robert G. Sullivan, Esq. explains why a previous c-section increases the risk of uterine rupture during natural delivery, and outlines the precautions hospitals must take to ensure that uterine rupture does not occur.
Uterine rupture during vaginal birth after Cesarean Section (“VBAC”) is most closely associated with a failure of the scar from the prior delivery. When the scar fails, its tissue separates or tears, injuring or rupturing the uterus in the process. There is an association with the location and type of scar in the uterus and the degree of risk of rupture.
A vertical uterine or T-shaped incision creates a scar most highly associated with the risk of a rupture. Such a scar is a known contraindication to VBAC. In contrast, a scar located lower on the uterus is less associated with the risk of rupture. There is also an association between the type of closure (suturing) of the prior uterine incision, regardless of the location, to the risk of rupture. A two-layered closure is associated with a decreased risk as compared to that associated with a one-layer closure.
When considering VBAC as an option, it is very important for a physician to obtain and carefully review the prior operative report. Having delivered their babies, most patients do not secure and keep copies of previous Cesarean Section reports. Women should consider doing this if they anticipate future pregnancies and the possibility of delivering at a different hospital.
Written reports enable doctors to ascertain the type of scar and its location. These documents also provide information about the type of closure. Equipped with this information, a physician may counsel a patient about the risks and benefits of VBAC. Many medical authorities question the safety of offering VBAC in the absence of a prior written operative report. There are some institutions, however, that will allow VBAC without such information. This policy is far from optimum.
In the absence of the written operative report and hospital chart, an informed decision as to VBAC can only be made if the patient provides a full medical history. Of course, patients’ memories are not perfect, and an expectant mother may not have available all of the relevant details of her previous deliveries. For non-English speaking patients, the use of a family member as an interpreter is fraught with the possibility of error or inaccurate translation.
Obtaining informed consent for VBAC requires a detailed discussion of the risks, alternatives and benefits of a planned repeat Cesarean Section. Many institutions recognize the significance of this issue and have specific consent forms for VBAC. Regardless of the form used, the written consent form must be written in simple words that can be understood by the patient as to the treatment and the risks involved.
As stated in earlier articles, the benefits of VBAC include the avoidance of surgery and the benefit of decreased blood loss, decreased post delivery complications associated with having surgery, and a shorter recuperative period. The major risk of VBAC is a ruptured uterus and the sequelae of that event. For a woman who had a prior low transverse uterine scar, the risk of uterine rupture is estimated as 1% or less. As small as it sounds, a 1% risk of rupture is not insignificant.
The risk of rupture increases four times when the prior closure of the incision was a single layer of sutures, versus a double layer. Although not an absolute contraindication to VBAC, single suture layering is a piece of information needed to assess the risk.
When the uterus does rupture, the risk of infant death and asphyxia is significant. The risk is estimated to be as high as 44.5 % in the case of a complete rupture of the uterus, where the infant is literally expelled out of the uterus.
In one particular case of VBAC that led to a medical malpractice suit, the hospital failed to obtain a written operative report of an earlier c-section. The patient did not speak English. Her doctors did not appreciate that the type of scar resulting from her previous delivery made her particularly susceptible to uterine rupture. Instead, relying upon summary information obtained from the patient through an interpreter, a decision was made to authorize VBAC. Uterine rupture took place during the delivery.
Although the infant survived, the young mother lost her uterus and all hope for future pregnancies. As the case proceeded, it became clear that the patient never appreciated or began to understand all of the risks the VBAC presented. She was not advised of the consequences of a uterine rupture.
Before considering VBAC, a patient is advised to have her physician review all records of her previous deliveries. A patient must fully appreciate and understand the dangers and benefits of VBAC, generally, and in her delivery in particular.
If you had one or more previous Cesarean deliveries, and sustained injuries during a later vaginal delivery, you should consult with a medical malpractice attorney. An experienced New York attorney will answer questions about potential legal actions available to you, and explain the basis for medical malpractice claims. In advance of commencing a lawsuit, qualified medical malpractice attorneys will work closely with experts in the fields of obstetrics and gynecology, and conduct a careful investigation of the care and treatment you received.