Category Archives: Pain Medications

Can you feel a uterine rupture with an epidural?

woman-laboring-hospitalSome care providers discourage epidurals in VBAC moms fearing that it will mask the symptoms of uterine rupture (namely abdominal pain) and delay diagnosis resulting in a poor outcome for baby and to a lesser extent, mom  Other care providers suggest or even require VBAC moms to have an epidural so that a cesarean can quickly take place if needed.  Which philosophy does the evidence support?

Review of 14 VBAC studies

I recently came across a study entitled “The Role of Epidural Anesthesia in Trial of Labor” (Johnson, 1990) that reviewed 14 VBAC studies.  Johnson found among scarred women who ruptured, a greater percentage of women with epidurals reported abdominal pain than women without epidurals.

  • 5 of 14 (35.7%) patients with an epidural who ruptured had abdominal pain.
  • 4 of 23 (17.4%) patients without an epidural who ruptured had abdominal pain.

Interestingly, only 22% of the women who ruptured in that study reported abdominal pain and Johnson concluded, “Thus abdominal pain is an unreliable sign of complete uterine rupture.”  But is it?  69% of women in Zwart (2009) reported abdominal pain. (I write about Zwart here and here.)

One difference between the studies is Zwart included significantly more scarred moms than Johnson: 26,000 versus 10,976.  The second different is that Zwart also included 332,000 unscarred women representing 93% of the sample population.

Unscarred moms, uterine rupture, and abdominal pain

I’m curious if the reason why Zwart reported such a high level of abdominal pain was because it included so many unscarred moms.  I wonder if unscarred moms are more likely to report pain and if so, why would that be.  Zwart combines the symptoms for scarred and unscarred rupture into one chart.  If they broke that chart out by scarred vs. unscarred rupture symptoms, would we see any major differences? Generally, unscarred rupture does more damage to the uterus and is more likely to result in an infant death (Zwart, 2009), so maybe because there is more damage, women report more abdominal pain?

Most common UR symptom: fetal heart tone abnormalities

I checked out  eMedicine’s article “Uterine Rupture in Pregnancy” and was fascinated to learn that several studies concur with Johnson.  They also found that abdominal pain is reported at a much lower rate than fetal distress/ abnormal fetal heart tones:

…sudden or atypical maternal abdominal pain occurs more rarely than do decelerations or bradycardia. In 9 studies from 1980-2002, abdominal pain occurred in 13-60% of cases of uterine rupture. In a review of 10,967 patients undergoing a TOL, only 22% of complete uterine ruptures presented with abdominal pain and 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring. [This is the Jonhson study.]

Moreover, in a study by Bujold and Gauthier, abdominal pain was the first sign of rupture in only 5% of patients and occurred in women who developed uterine rupture without epidural analgesia but not in women who received an epidural block.  (Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors?. Am J Obstet Gynecol. Feb 2002;186(2):311-4).  Thus, abdominal pain is an unreliable and uncommon sign of uterine rupture. Initial concerns that epidural anesthesia might mask the pain caused by uterine rupture have not been verified and there have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture.

A 2012 study out of the UK (Fitzpatrick, 2012) also reported that 76% of uterine ruptures were accompanied by fetal heart rate abnormalities in comparison to 49% reporting abdominal pain.

ACOG’s stance on epidurals

It’s important to note that ACOG does support the use of epidurals in VBACs:

Epidural analgesia for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC (109, 110). No high quality evidence suggests that epidural analgesia is a causal risk factor for an unsuccessful TOLAC (44, 110, 111). In addition, effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture, particularly because the most common sign of rupture is fetal heart tracing abnormalities (24, 112).

Remember that fetal heart tracing abnormalities were detected in 76% of the ruptures in Johnson ad 67% of the ruptures in Zwart.

I couldn’t find any mention of epidurals masking rupture pain in the Guise 2010 Evidence Report, but found that the Johnson study was excluded from their report because “No full-text paper, opinion or letter with no data.”  Interesting.

Uterine rupture symptoms

A list of uterine rupture symptoms and their frequency per Medscape’s article on uterine rupture.

  • “80% Prolonged deceleration in fetal heart rate or bradycardia
  • 54% Abnormal pattern in fetal heart rate
  • 40% Uterine hyper-stimulation
  • 37% Vaginal bleeding
  • 26% Abdominal pain
  • 4% Loss of intrauterine pressure or cessation of contractions”

A couple notes.  One, abdominal pain is not a consistent or reliable symptom of UR.  Two, there is a level of interpretation that goes into diagnosing abnormal fetal heart tones even among people who have extensive medical training.

Additional symptoms that I have collected from other sources include:

  • Baby’s head moves back up birth canal
  • Bulge in the abdomen or under the pubic bone (where the baby may be coming through the tear in the uterus)
  • Uterus becomes soft
  • Shoulder pain

Risks and benefits of epidurals

As with every option available to you regarding birth, it’s always good to be knowledgeable on the risks and benefits of epidurals so you can make an informed choice.  Three excellent resources are this article by Sarah Buckley MD, the PubMed Health Epidural Fact Sheet and this review of epidural research by the Cochrane Library.

Take home message

The limited information available tells us that epidurals do not mask abdominal pain from uterine rupture.

The most common symptom of uterine rupture is fetal distress diagnosed by fetal heart rate abnormalities.

Epidurals may be used during a trial of labor after cesarean per ACOG.


As always, if you can offer further research or perspective on this topic, please leave a comment.  Our knowledge is constantly growing and we can only work with the best information available to us now.  Who knows what future research will tell us?

Neonatal nurse has a homebirth VBAC

This is a great birth story, published with permission, of a woman who had a cesarean for “small pelvis” and then VBACed a larger baby at home!  Since she is a neonatal nurse, it’s interesting to read why she chose HBAC and how she thinks her birth would have gone differently had she labored in a hospital.

I just wanted to let everyone know that I gave birth to a healthy baby
girl Wednesday June 11th. I had a C/S with my son 2 years ago. He was
8lbs 2oz and I was told that my pelvis wasn’t big enough to birth an
8lb baby. Well my VBAC baby was 9lbs 2 oz. Exactly a pound bigger than
they told me. I knew I wasn’t broken. I chose to have a homebirth
because I felt I would always have to fight for what I wanted in the
hospital. My labor went great. Started around 3am contractions coming
10 minutes apart. Then progressed to 3-5 min apart at around 6:30am.
My midwife got there around 7:30am. Later I wanted to go into the
birthing tub to try to get through the contractions. My midwife wanted
to check to see how far I was. 4cm and 100% effaced. She told me to
try to hold off on the tub because it would be better when I am
further in labor. I then took a hot shower. For me the contractions
were more bearable standing up. When one would come on I would bend my
knees and lean over onto either the couch, my bed or my husband. The
worse position for me to labor on was my back and my side. After the
shower I asked if I could go into the tub again. She checked me and I
was 6cm with a bulging bag. I did go into the tub which for me didn’t
make much difference in the contractions. But at that point I stayed
in there for quite a while because it took too much energy for me to
move. For me the worse part was going from 6 cm to complete. I thought
it would have been the pushing part but it wasn’t. In the tub I did
feel like pushing a little bit. We couldn’t tell if my water had
broken since I was in the tub. I decided to get checked in the tub to
see if the water had indeed broken and plus since I was feeling
“pushy.” Still at 6cm but the bag was bulging more. They think that
was why I was feeling like I had to push. They let me push a couple of
pushes to see if that would break my water but it didn’t. Then they
told me not to push and just try to breath through the contractions.
My water still wasn’t breaking and it was the hardest thing trying not
to push when that overwhelming feeling was there. They gave me the
option of breaking my water and felt that once they did that the
baby’s head would apply to the cervix and help with dilation. I
agreed. They broke the water and sure enough baby’s head came right
down and I was 8-9cm. The pushing feeling let up and I labored more
for a while. I then started feeling pushy again and they decided to
check to make sure I was fully dilated before I fully pushed. I just
had an anterior lip. Again they told me not to push so that the
anterior lip would pull back over the baby’s head and not swell. I was
dying to push but breathed through each contraction for an hour or
two. (I lost all sense of time so I don’t know exactly how long it
was) The best position for me was on my hands and knees but they said
that with the anterior lip that the position was actually making it
worse. They wanted me to lie on my back to help take pressure off the
cervix to facilitate it moving around the baby’s head. Lying on my
back was so unbearable but I did it to help with the dilation. The
midwife decided to try to help push the cervix over the head. She told
me to push while she held it out of the way. Finally her head came
down and I could fully push to my heart’s desire. That felt great.
They asked if I wanted to go back to the hands and knees position
since the cervix isn’t an issue now but I said I just could not bear
to move to another position. Then the “ring of fire came” Boy did that
burn. Finally her head came out and, surprise, so did a hand. They
said that her hand was across her face. They pulled the hand out along
with the head and since one shoulder was in and one was out she was
having a little bit of trouble maneuvering. They wanted me to flip to
my hands and knees to open up the pelvis more. I thought they were
crazy. Me trying to flip over with a head hanging out. I knew that I
just had to do it as quickly as I could or it wouldn’t have gotten
done. My husband said he had never seen me move so quickly in my life.
I pushed a little more and she was out! Amazingly I had no tears.
Personally I thought that was pretty amazing to have my first full
term vaginal birth of 9lbs 2oz with no tears what-so-ever! So to all
of those women who have been told that you would have died in
childbirth because you couldn’t push out your own baby YOU CAN! I am
proof that I delivered a baby 1 pound bigger than what they said.
I am an RN in labor an delivery and see all of the unnecessary
interventions that they do. I was pondering about my birth. If I would
have chosen a hospital birth I probably would have ended up with
another c/s or an episiotomy. There were times during my birth where I
thought am I crazy I can’t deal with this pain. The midwives and doula
helped me through the intense contractions. If I was at the hospital
they would have bullied me into an epidural and therefore I wouldn’t
have been able to move around to get her to come down. Also I wouldn’t
have been able to feeling the progression of her head coming down when
I pushed. With my son I pushed and couldn’t really feel any progress
so mentally I was losing hope. With this birth it didn’t feel like I
pushed for an hour because I could feel the accomplishment of her
coming down. I see this happen all of the time at the hospital. If a
mom isn’t pushing quick enough for the Dr or they think the head is
too big then they will automatically do an episiotomy. They probably
would have done that and it just shows that it would have been for
nothing and I would have had a longer recovery time. So therefore I am
grateful that I found homebirth and such wonderful midwives. Any of
you who are contemplating homebirth vs hospital try your best to do
homebirth. Don’t let money be an issue. After all is said and done
money is money. You can always earn the money back but not the
experience of a wonderful birth. I hope this inspires all of you who
are having the normal feelings of “what if I can’t do it.” Good luck
to your future births, You CAN do it!