Learning Objectives
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List risk factors for uterine rupture.
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Recognize signs of uterine rupture.
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Describe management of uterine rupture.
Uterine rupture, also known as uterine dehiscence, refers to the total or partial disruption of the uterine layers ( Fig. 16.1 ). It is a life-threatening emergency for both the mother and fetus. Most commonly uterine rupture occurs in the context of a “scarred uterus.” A “scarred uterus” includes one with any previous uterine surgery, including prior cesarean delivery or myomectomy, especially if the contractile portion of the uterus has been entered.
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In high resource countries, uterine rupture is mainly related with trial of labor after cesarean section (TOLAC). In low resource countries, uterine rupture is associated with “obstructed labor.”
Risk Factors
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Prior uterine rupture
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History of classical cesarean
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Prior myometrial surgery
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Exposure to uterotonics
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Labor
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Multiparity
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Advanced maternal age
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Abnormal placentation
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Short interpregnancy interval
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Macrosomia
A prior vaginal delivery decreases the risk of uterine rupture, either before or after a prior cesarean section.
Unfortunately, there are no accurate and clinically useful predictors of uterine rupture; consequently, a high index of suspicion is needed. Whenever TOLAC is attempted, continuous fetal monitoring is recommended.
Intrapartum Signs and Symptoms
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Fetal heart rate abnormalities: This is the most common sign of uterine rupture although no specific pattern is pathognomonic of rupture. Fetal bradycardia is the most common abnormality ( Fig. 16.2 )
Fig. 16.2 Fetal heart rate changes are the most common signs of uterine rupture. - •
Sudden onset or worsening abdominal pain; regional anesthesia may mask or attenuate this symptom
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Vaginal bleeding
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Loss of fetal station
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Hematuria
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Hemodynamic changes, secondary to acute blood loss from intraperitoneal hemorrhage
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Change of contractions pattern
Postpartum Sign and Symptoms
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Persistent pain
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Persistent vaginal bleeding
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Hematuria
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Hemodynamic changes, secondary to acute blood loss from intraperitoneal hemorrhage
Uterine Rupture SimulationMaterials Needed
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Manikin or volunteer to act as standardized patient
Key Personnel
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Anesthesiologist
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Attending obstetrician
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Neonatologist
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Resident physician (if available in your institution)
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Two nurses
Sample Scenario
Ji-Young is a 26-year-old G2P1 at 38 weeks 4 days gestation presented in labor. She has a history of one previous cesarean delivery and is highly motivated for vaginal delivery. Her initial exam is 5 cm dilated, 50% effaced, and −1 station. She is admitted and is preparing for an epidural when she experiences sudden worsening of pain. The fetal heart rate tracing shows a prolonged deceleration to 60 beats per minute.
Debriefing and Documentation
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Risk factors for uterine rupture
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Time uterine rupture recognized, how diagnosis was made
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Time emergency response protocol initiated
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Time in OR
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Time of delivery
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Interventions implemented while preparations were done for emergency delivery
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Review of continuous fetal heart rate monitoring, did it take place?
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Type of anesthesia used
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Surgical technique employed to manage the rupture
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Description of maternal and neonatal condition.
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Fetal weight
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Cord gas
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APGAR scores
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Resuscitation
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Communication with patient and family
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