Once considered unthinkable, vaginal delivery after a previous caesarean section remains a safe option for many women. One of the greatest concerns for patients, providers, hospitals, and policy makers with regard to vaginal delivery after prior caesarean is the potential for devastating consequences such as perinatal death from uterine rupture. Although the risk factors associated with uterine rupture have been investigated often, few studies have attempted to measure mortality and morbidity directly related to uterine rupture, and none has examined whether outcomes related to uterine rupture are related to the number of births per year in the hospital. This editorial discusses the current evidence regarding risk factors for catastrophic uterine rupture and possible preventive measures, and considers the importance of framing risk in policy, and discussions between provider and patient.