Uterine rupture

Question 1

What is uterine rupture?

Answer 1

-complication of labour where myometrium ruptures

Question 2

What is an incomplete rupture or uterine dehiscence?

Answer 2

-perimetrium (serosa) surrounding the uterus remains intact

Question 3

what is a complete rupture?

Answer 3

where the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity

Question 4

What does uterine rupture lead to?

Answer 4

• significant bleeding
• baby may be released from the uterus into the peritoneal cavity
• has a high morbidity and mortality for both the baby and mother.

Question 5

What is the main risk factor for uterine rupture?

Answer 5

• previous caesarean section
• scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin)
• extremely rare for uterine rupture to occur in a patient that is giving birth for the first time

Question 6

What are the other risk factors for uterine rupture?

Answer 6

• Vaginal birth after caesarean (VBAC)
• Previous uterine surgery
• Increased BMI
• High parity
• Increased age
• Induction of labour
• Use of oxytocin to stimulate contractions

Question 7

What does a uterine rupture present with?

Answer 7

• an acutely unwell mother and abnormal CTG
• may occur with induction or augmentation of labour, with signs and symptoms of:

>Abdominal pain
>Vaginal bleeding
>Ceasing of uterine contractions
>Hypotension
>Tachycardia
>Collapse

Question 8

What is the management of uterine rupture?

Answer 8

• is an obstetric emergency
• Resuscitation and transfusion may be required
• Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).

Question 9

A 36-year-old para 2 woman is in active labour with regular contractions. She is 6cm dilated when she suddenly complains of intense abdominal pain and loss of contractions. The midwife is unable to obtain a trace through cardiotocography.

Her past medical history includes hypertension and a previous caesarean section for foetal distress.

What is the most appropriate management?

A. IM oxytocin to expedite delivery

B. Massage the uterus to encourage contractions

C. Assess the foetus with ultrasonography

D. Emergency laparotomy

E. Call for help and attempt McRobert’s manoeuvre

Answer 9

D. Emergency laparotomy

The sudden onset of abdominal pain and loss of contractions during labour, especially in the context of previous caesarean section, strongly suggests uterine rupture. This is an extremely rare obstetric emergency that carries a high mortality risk for the mother and the baby. Therefore, emergency caesarean section in the delivery room should be performed without delay rather than transferring the patient to theatre, as the mother is at risk of haemorrhagic shock. Although uterine repair should be attempted following delivery, a caesarean hysterectomy is often necessary.

Question 10

Risks of VBAC:

Answer 10

-Increased risk of uterine rupture (scar rupture)
-Increased risk of requiring caesarean section (failed VBAC)

VBAC usually has a success rate of around 60-80% (75%)

Question 11

Contraindications to VBAC:

Answer 11

1. Classical (vertical) caesarean scar
2. Previous history of uterine rupture
3. the usual contraindications to a vaginal delivery (such as major placenta praevia)