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  6. Uterine Rupture (565)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Uterine Rupture (565)

Please report any inaccuracies or issues with this guideline using our online form

Ruptured uterus most commonly occurs in women attempting VBAC, at a rate of approximately 1 in 200 (0.5%). However, it is a risk in any labouring woman. It is a very rare complication in primigravidas. 

Prompt diagnosis and treatment are crucial if the baby is to be born alive. Delays in diagnosis may lead to severe maternal morbidity and mortality. 

Risk factors include:  

  • Previous caesarean section
    • Note the 2-3 fold increase in rupture rate in induced/augmented labours vs spontaneous.
  • Previous uterine trauma/surgery e.g. myomectomy.
  • Late medical termination of pregnancy or medical management of pregnancy loss – particularly with history of previous section/uterine surgery.
  • Oxytocin use in multiparous patients.
  • Malpresentation/obstructed labour.
  • Mullerian tract anomalies. 

Clinical presentation:

  • Commonest sign is prolonged fetal heart deceleration (in 70%).
  • Other signs are pain and bleeding, both of which are unreliable (in only 7.6% and 3.4%, respectively) and often seen in labouring women without rupture. 
  • Unexplained maternal tachycardia/hypotension/syncope.
  • Cessation of uterine contractions associated with suspicious/pathological CTG is particularly suggestive of uterine rupture.
  • Presenting part may no longer be in pelvis or at a ‘higher station’.
  • Pathological pain will usually come through an adequate epidural.
  • Pain may be located to ‘unusual’ sites e.g. shoulders, vulva/perineum, buttocks.

ACTION PLAN

1. Suspect – beware of pathological CTG in association with a risk factor for uterine rupture (usually previous caesarean section).

2. Call anaesthetist and senior obstetrician.

3. Airway

Assess. 

Maintain patency. 

Breathing

Assess. 

Attach pulse oximeter to patient.

Apply oxygen 15 litre/min via face mask with reservoir bag. 

Circulation

Assess pulse and BP – put on ECG and automatic BP monitor.

Secure IV access using two large bore cannulae.

Fluid resuscitation as required.

Send bloods for FBC, cross-match 4 units and clotting screen.

Treat peri-arrest arrhythmias.

CPR if necessary.

4.If baby alive and criteria for safe instrumental delivery are fulfilled, then this may be carried out.

5. Proceed to urgent laparotomy, which may require general anaesthetic, with senior anaesthetist attending. In general a previous low transverse scar can be re-opened. In certain circumstances a mid-line incision should be considered.

6. The type of operation performed is dictated by the size and site of rupture, the degree of haemorrhage and the patient’s future fertility wishes – see further information below.

7. Give prophylactic antibiotics.

8. Document fully in notes with date and time.

9. Debrief patient and family.

Further information

The type of operation performed is dictated by the size of rupture, the degree of haemorrhage, and the patient’s future fertility wishes.

  • Dehiscence of the lower uterine segment in association with a previous caesarean section is the most common operative finding.
  • The rupture may extend anteriorly towards the back of the bladder, laterally towards the uterine arteries, or into the broad ligament plexus of veins and thereby lead to a massive haemorrhage.
  • Posterior rupture may occur and is usually associated with intrauterine malformations but has occurred in patients who have had a previous caesarean section and an obstructed labour and also after a rotational forceps delivery.
  • If repair is attempted then it is important to first secure haemostasis and check for damage to the bladder or ureter. Look for broad ligament bleeding points and check no haematomas are present / developing. A large (14g F) pelvic drain is recommended.
  • If complex repair, consider asking for Gynaecology consultant on call to attend. The presence of a second consultant would be required in event of hysterectomy being necessary.
  • Urological damage is likely to be complex: request specialist urological surgical opinion.
  • If the apex of a tear is not easy to identify, consider placing at least one proximal suture and applying gentle traction. Often the apex can then be identified.
  • Sustained haemorrhage is an indication for performing a total or subtotal hysterectomy. Subtotal hysterectomy is a simpler procedure than total hysterectomy and reduces the risk of damage to the bladder and ureter. Alternative strategies may be appropriate for continuing haemorrhage despite uterine repair (see massive obstetric haemorrhage protocol).
  • Total hysterectomy may be performed, depending on the experience of the operator and the condition of the patient. The prime consideration is to preserve the patient’s life.
  • The ovaries should be conserved in the absence of truly exceptional circumstances.

Editorial Information

Last reviewed: 24/12/2020

Next review date: 01/12/2023

Author(s): Victoria Flanagan.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Reviewer name(s): Dr Roslyn MacBride (ST4)/Dr Victoria Flanagan (Cons) .

Document Id: 565