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.
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.
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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 Simulation
Materials 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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