Uterine Rupture (565)

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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