Podcast Summary: Can SVD Occur After Pelvic Fracture?

Dr. Chapa’s Clinical Pearls | September 3, 2025

Main Theme / Purpose

This episode tackles a common but nuanced clinical question:
Can a woman with a prior pelvic fracture — particularly with fixation hardware — safely attempt a spontaneous vaginal delivery (SVD), or is cesarean section (C-section) required?
Dr. Chapa uses a recent real-world case as the springboard for a lively, heavily evidence-based exploration, blending recent literature, orthopedics perspectives, and practical counseling pearls for clinicians.

Key Discussion Points and Insights

1. The Real-World Clinical Scenario ([00:36])

• Patient Background: Dr. Chapa recounts a case in clinic—a late-teen pregnancy intake. The patient had a "U fracture" of the sacrum (from an MVA a year prior), treated surgically with pinning, now ambulatory with no residual issues.
• Central Concern: The patient, misinformed by a non-medical friend, fears she must have a C-section due to her prior pelvic fracture.
• Framing the Core Question:
  “If you have a patient who has a pelvic fracture... and she has some fixation points... Would you allow that patient to have a vaginal delivery?” ([04:16])

2. Incidence and Relevance: Why This Matters ([06:30])

• Pelvic Fractures in Reproductive-Age Women:
  • Incidence: 34.3 per 100,000 (AJAAOS, 2024)
  • “Women account for about 69% of these injuries, 23% of which occur in women of childbearing age.” ([07:13])
• Takeaway: Clinicians likely to encounter these scenarios; the question is practical, not rare.

3. Essentials of Pelvic Mobility in Childbirth ([09:29])

• Bony Pelvis in Labor:
  Movements of the pelvis (sacroiliac joints, pubic symphysis, sacrum) are crucial for fetal descent—so "intuitively," restricting these could threaten vaginal delivery.
• Data from Czech Gynecology (2024):
  Dr. Chapa reviews a study on pelvic bone movement during delivery, emphasizing that fixation can raise concerns—especially for patients and clinicians new to post-fracture deliveries.

4. What the Evidence Says: Attempting Vaginal Birth Post-Fracture ([12:00], [13:45])

• Orthopedic Literature Review:
  “Orthopods... actually are very pro vaginal delivery... with one big caveat.” ([12:23])
• Observational Data: Cesarean rates in this group are increased (up to 47%), but:
  • It is unclear if this is due to anatomical issues or rather "patient fear, physician fear—that's called physician bias.” ([12:59])
• Key Point: For remote, healed fractures (not acute, no hematoma, hardware not crossing pubic symphysis), SVD can generally be attempted.
• Two Essential Caveats:
  1. Increased C-section rate (need to set patient expectations)—but causation is unclear.
  2. Absolute contraindication is likely when hardware bridges the pubic symphysis.
     “If there is a fixation point... that spans the pubic symphysis... those may not labor well, okay? There has to be a normal movement of the pubic symphysis...” ([14:35])

5. Mechanisms & Intuition vs. Evidence ([15:27])

• Pelvic Mobility Recap:
  • Sacroiliac movement, pubic symphysis widening, and "nutation" (forward tilt of sacrum) all matter.
  • Complete immobilization is rare—most fixations still permit some movement, unless the pubic symphysis is fixed.
• European Journal of Obstetrics & Gynecology (2022):
  “Vaginal delivery has been found to be the primary mode of delivery even in women with a pelvic fracture, with or without fixation.” ([16:53])
  • Yet, defining the "true" rate of successful SVD is difficult due to bias and preference leading to earlier C-sections.

6. Review of Seminal Literature and Key Quotes

a) Orthopedic Surgery Perspective ([20:29]):

• 2024, AJAAOS Global Research Review:
  • “At this time, there is no clear evidence to support an elective cesarean section as the sole indication after a prior pelvic fracture.” ([20:29])
  • “Until the increased cesarean section rate has been explained as truly coming from an obstetrical complication, counseling the patient to avoid vaginal delivery is problematic.” ([21:08])
  • Dr. Chapa’s reaction: “Man, is that—I mean, I got orthopods fighting for vaginal delivery. What? I mean, insane.” ([21:22])

b) International Orthopedics, 2023 ([22:00])

• “Reported cesarean section rates after pelvic fracture are higher... The reason... is unknown. It can be assumed that the lack of literature regarding the safety of vaginal delivery... may influence patients and obstetricians to prefer an elective C section.” ([22:32])
• Takeaway: Uncertainty—not evidence—may be driving higher C-section rates.

c) Orthopedic Trauma Association Conference, 2009 ([23:45])

• “A common thought process in the lay population and even in the obstetric community is that women who have had pelvic fractures cannot deliver vaginally. However, there is no large scale study to corroborate this.” ([24:00])
• 42% rate of NSVD after pelvic fracture (excluding those with symphysis fixation).
• “There was no patient with successful normal spontaneous vaginal delivery with transymphyseal fixation, and the women were not given a trial of labor.” ([25:11])
• Implication: Zero successful SVD with symphysis fixation—though this may reflect lack of trial more than absolute anatomical impossibility.

7. Practical Counseling for Patients ([26:27])

• Summary Counseling Points:
  • “Having a history of pelvic fracture and pelvic bone hardware is not by itself an absolute contraindication for vaginal delivery—unless there’s pubic symphysis fixation...” ([17:58])
  • “Barring some other issue that comes up... this by itself should not be an indication [for C-section].” ([26:27])
• Patient Reassurance: Dr. Chapa’s patient reassured she can attempt vaginal delivery, with the usual caveats about trial of labor.

Notable Quotes & Moments (with Timestamps)

• Framing the clinical dilemma:

  • "One of my friends told me I needed a C section because of my pelvic fracture. Now, mind you, her friend who's another teenager, is not medical at all." — Dr. Chapa ([03:40])

• Orthopedic-OB rivalry humor:

  • "Bbmf. Bbmf. That is a typical orthopedic progress note... Bone broke me fix." — Dr. Chapa ([11:59])
  • “Orthopods... are very pro vaginal delivery... My ortho bros. Gotta love my ortho bros.” — Dr. Chapa ([12:23])

• Meta-analysis on why C-sections are higher:

  • "It's difficult to figure out if those patients had a section because of patient fear. Physician fear. That's called physician bias." — Dr. Chapa ([13:01])

• Crux of clinical evidence:

  • “At this time, there is no clear evidence to support an elective cesarean section as the sole indication after a prior pelvic fracture.” — Dr. Chapa quoting 2024 AJAAOS ([20:29])
  • “...counseling the patient to avoid vaginal delivery is problematic.” — Same source ([21:08])
  • "The symphysis has to have a little bit of movement to allow for that shoulder to come through. It just has to. And fetal head delivery." — Dr. Chapa ([25:13])

• Key Counseling Takeaway:

  • "She was very reassured that her history of pelvic fracture did not mandate a cesarean section. So, yes, vaginal delivery is possible." — Dr. Chapa ([26:27])

Important Segment Timestamps

• [00:36] Case introduction and clinical question
• [06:30] Pelvic fracture incidence, epidemiological relevance
• [09:29] Pelvic movement in labor (Czech Gynecology review)
• [12:00] Ortho-OB perspectives, higher C-section rates—why?
• [13:45] Criteria for SVD attempt; absolute contraindications
• [15:27] Intuition vs. evidence: biomechanics vs. outcomes
• [16:53] European literature: SVD typically possible after fracture
• [20:29] 2024 key orthopedic journal quote
• [22:00] 2023 and 2009 supporting studies; focus on symphysis fixation
• [26:27] Final counseling and reassurances for patients

Conclusion: Clinical Pearls Recap

• Remote, well-healed pelvic fracture (even with hardware, unless at the pubic symphysis) does NOT mandate elective C-section.
• Inform patients:
  • C-section rate may be higher in this cohort but is not clearly due to biomechanical obstruction.
  • Success of SVD hinges on site of fixation (pubic symphysis being the main anatomical 'dealbreaker').
• Key Literature: Multiple recent (2024, 2023) and older sources agree — elective C-section as mainstay is unsupported by data.
• Shared Decision-Making is vital, with accurate, evidence-based counseling to counteract patient/physician bias.

Dr. Chapa’s Signature Tone:

• Evidence-based, practical, and approachable—with humor, “ortho bro” banter, and frequent direct quotes from current literature.
• Above all, a focus on clear patient communication and individualized, myth-busting counseling.