Uterine Rupture

Question 1

What is uterine rupture?

Answer 1

• it is a serious complication in which the wall of the uterus tears
• it can be complete —> a defect involving the full thickness of the uterine wall and uterine serosa with or without expulsion of the fetus into the abdominal cavity
  —> it can result in severe maternal morbidity and mortality as well as possible fetal death, occurs in 1.9/10000
• or it can be incomplete —> occurs when the tear does not extend through the full thickness of the uterine wall and the peritoneum remains intact
• or dehiscence of an existing scar may take place —> visceral peritoneum remains intact and clinically less significant bleeding takes place from the edges of a pre existing scar, the fetus placenta and umbilical cord remain inside the uterine cavity, occurs in 4% of labours and 0.4% of pregnancies

Question 2

What are the risks and pre-disposing factors?

Answer 2

• previous Caesarean section or other uterine surgery e.g. myomectomy
• previous classical incision
• multiparity
• pharmacological induction of labour/augmentation (prostaglandins and syntocinon)
• previous uterine rupture
• abnormal placentation
• congenital uterine anomalies
• trauma to the abdomen
• intrauterine manipulation or interventional procedures
• obstructed labour

Question 3

What are some of the issues in recognising uterine rupture?

Answer 3

• signs and symptoms can vary greatly dependent on the timing, site and degree of the uterine rupture
• uterine rupture at the site of a previous uterine scar is typically less harrowing than a spontaneous rupture because of its reduced vascularity
• the signs and symptoms can be inconsistent and can have similarities to those of a concealed abruption
• signs and symptoms may also be concealed by medical conditions e.g. pre eclampsia or certain prescribed drugs masking tachycardia or epidural infusion

Question 4

What are the main signs and symptoms?

Answer 4

• fetal heart rate abnormalities —> bradycardia is the most common indicator
• diminished or slowing of uterine contractility —> would previously have had effective uterine contractions, may then be followed by a bradycardia
• pain —> usually of sudden onset, and above and beyond that of normal labour pain and the abdomen will be tender to touch
• bleeding —> vaginal bleeding is a rare occurrence, bleeding is usually behind the presenting part, it may not be visualised until after delivery as a PPH.
  —> haematuria is often seen, especially if a urinary catheter is present as the bladder may be adherent to a previous uterine scar
  —> bleeding into the abdomen can be profuse especially if the tear is longitudinal rather than transverse with the woman displaying signs of shock or even sudden collapse
• abdominal palpation —> a bandl ring is a pathological retraction ring and may be palpable, can be described as a late warning sign of impending rupture
  —> following a uterine rupture, on examination a loss of uterine contour may be identified and two swellings may be prominent; one is the fetus lying in the abdominal cavity and the other is the contracted and retracted uterus, the fetal parts may then be easily palpable
• maternal vital signs —> tachycardia, hypovolaemic shock, the woman be initially be restless before any vital signs of shock are evident

Question 5

How should it be managed in hospital?

Answer 5

• summon urgent help (3 buzzers, 2222, SOAPS)
• discontinue oxytocin infusion if in use
• administer facial oxygen and begin resuscitative treatment for management of shock, 2 cannulas, blood for crossmatch, IV fluids, monitor vital signs
• prepare for surgical delivery
• record keeping