Introduction:

Uterine rupture is a serious complication of labour, causing maternal and fetal morbidity and
mortality around the globe, although much more frequently in low-income countries. When
uterus ruptures there may be a direct communication between uterine cavity and peritoneal
cavity (complete rupture), or peritoneum or bladder may separate the baby from peritoneal
cavity (incomplete rupture, less common). If the membranes ruptured some time before
delivery, the contents of the uterus will be infected, and uterine muscle bruised and in poor
condition for repair.

Definition:
A uterine rupture is defined as the separation of the pregnant uterine wall, with or without
expulsion of the foetus (Park EH 1999). It is a serious complication of labour that can lead to
fetal death and contributes to maternal morbidity and mortality.

Another definition is disruption in the continuity of the all uterine layers (endometrium,
myometrium and serosa) any time beyond 28 weeks of pregnancy is called rupture of the
uterus.

Incidence:
Occurs in 0.4-0.6 of all deliveries.

A WHO systematic review of maternal mortality and morbidity in 2005 showed large
differences in the incidence of uterine rupture among countries. In high-income countries the
incidence of uterine rupture was approximately 1% in women with a history of caesarean
delivery, and less than 1 per 10,000 in women with an unscarred uterus.

Causes:

1. A traumatic uterine rupture can be associated with the following:

 Poor management of induction of labour or acceleration.

 Use of oxytocics.

 High cavity instrumental rotational forceps.

 Manipulation to correct an unstable lie or malpresentation.

 Manual removal of placenta.

 Shoulder dystocia.

 Use of fundal pressure in the second stage of labour.

  Blunt or direct trauma e.g. traffic accident.

2. Spontaneous uterine rupture can be associated with:

 Previous uterine surgery

 Strong uterine contractions without use of oxytocics

 Unrecognised previous uterine trauma e.g. weakening of the uterine wall during
curettage.

 Obstructed labour

 Placental abruption

Sign and symptoms of rupture uterus:

Signs and Symptoms vary greatly and depend on the stage of labour and degree of rupture or
dehiscence

 Before delivery the main sign of uterine rupture is prolonged fetal bradycardia.
 Vaginal bleeding,
 Abdominal tenderness,
 Maternal tachycardia,
 Circulatory collapse out of proportion to the amount of blood loss externally, or
 Increasing abdominal girth each may herald a uterine rupture.

Investigations:

 Ultrasound can show an abnormal fetal position or extension of fetal extremities or

haemoperitoneum.
 Intrauterine pressure catheters are sometimes used but may fail to show loss of uterine
tone or contractile patterns following uterine rupture.

Rupture of the uterus diagnosis:

Impending rupture:

 Bandl's ring between the upper and lower segments rises.

 The lower segment becomes stretched and painful to touch, even between
contractions, which increase in strength and duration.

 The patient becomes anxious and restless, with a rapid pulse and irregular respiration.
 Actual rupture:

 Uterine contractions stop suddenly and are replaced by no pain (common), or less
pain, or severe continuous pain (uncommon).
 Mother is shocked and pale before delivery, or she becomes shocked afterwards, and
does not respond to transfusion immediately (especially if the placenta is retained).
 She may bleed from her vagina, sometimes quite severely, sometimes not at all. If the
presenting part is jammed in her pelvis no blood can escape from her vagina.
 Her uterus is tender to palpation (it may feel soft, or be permanently tense). Later, her
entire abdomen may be tender.
 The baby may be abnormally difficult to feel (common) or abnormally easy
(uncommon). Sometimes, the shape of her uterus changes, and you may be able to
feel him outside it (usually his limbs are close under her abdominal wall, a certain
sign of rupture). If he is in her broad ligament, you will be unable to feel him.
 The head may previously have been low in her pelvis, but has now risen higher and
may now be no longer palpable vaginally.
 Blood stained urine.
 The absence of a fetal heartbeat, unless the tear is a small one, and he is still in her
uterus.
 The appearance of the placenta at her vulva before she is delivered (uncommon).
 The prolapsed of loops of gut into her vagina (uncommon).

Differential diagnosis:

Rupture of the uterus is not the only cause of collapse during an obstructed labour, it can also
be due to

 Septic shock

 Electrolyte imbalance, or

 Dehydration

Management in hospital

Management should follow the following

 Stop oxytocin if it is being used.
 Summon help.
  Should include senior obstetricians, anaesthetists and paediatricians. Resuscitate and
treat the shock.
 IV access – 2 wide bore cannulas
 X match 6 units blood
 Prepare to go to theatre as soon as possible once the patient is stabilised

Management at home:

 Early recognition of signs and symptoms is essential.

 Summon help. Call paramedics/ambulance to arrange immediate transfer to hospital.
 Alert the maternity unit.
 Resuscitate and treat shock whilst waiting for paramedic assistance.

Resuscitation:

 Resuscitation must be done vigorously in the theatre or the labour ward.

 Internal jugular or subclavian puncture is better than a cut down.

 Mother is to be given at least a litre of 0.9% saline before anaesthesia starts, and 100
mmol of sodium bicarbonate to correct her acidosis.

 Operation to be done as soon as possible.

 Resuscitate to be continued while operation is going on.

 Two drips, one for saline or Ringer's lactate given fast, and the other for blood to be
given.

 If she is sufficiently conscious to understand, explanation is to be given that her tubes

to be tie. If she is not fit enough to understand, her relatives will must be explained.

Perioperative antibiotics

Avoid gentamicin before anaesthesia

Equipment:

A ''Caesar set' and some large curved clamps or artery forceps. Besides these a scrubbed
second assistant, the scrub nurse, the anaesthetist, and a ''runner'.

Anaesthesia:

A nasogastric tube to be passed to aspirate her stomach and also instillation of 30 ml

magnesium trisilicate to be done
(1) If general anaesthesia is given then intubation to be done under cricoid pressure.

(2) If her condition is poor, local infiltration anaesthesia will be safest.

(3) A ketamine drip to be started. Subarachnoid or epidural anaesthesia should be avoided

because she is already hypotensive.

Exploration for rupture of the uterus:

 Clip or shave her, wash her abdomen, and pass a catheter. This will prevent
mistakenly opening a high full bladder. Make a low midline or paramedian incision
and insert a self-retaining retractor.

 Blood will be seen, and a tear in her uterus. Her dead baby (common) and the placenta
(sometimes) may be in her peritoneal cavity. If the placenta is still attached to her
uterus, the foetus may be alive (rare), even if the foetus is lying free in her peritoneal
cavity. If it is detached, the baby will be dead, wherever the baby is.

 If the baby is lying free in her peritoneal cavity, the rupture is complete. Remove him.
If he is in her broad ligament, open it. This is most easily done by dividing the round
ligament over it.

 If the baby is still in her uterus, as with a posterior rupture, deliver him through a
transverse incision in the lower segment, as for caesarean section.

 Suck out blood and liquor. There may be bleeding, or this may have stopped,
especially if the tear is transverse across the vessels.

 If ergometrine is not given then it should be given as soon as the baby is delivered.
The head of the table to be lowered and pack off her gut.

 Deliver the empty uterus into the wound and inspect it, especially its posterior wall
there may be a second tear. Find the edges of the tear along its whole length. Divide
her round ligament if this makes the tear easier to see.

The tear may:

 Be in the anterior wall of her uterus, often with a vertical extension at one
end, making it L shaped.

 Extend into her bladder.

 Extend longitudinally, along the lateral wall of her lower segment, from her
fundus to her vagina, opening up her broad ligament and involving a uterine
artery.
  Extend transversely across the posterior wall of her uterus (rare).

 Detach the uterus almost completely (rare).

 Be in the upper segment through the scar of an old classical Caesarean

section. Often, one of her uterine pedicles is torn across.

 Placenta to be felt and it should be detached from the uterus with fingers. Swabs also
to be used on a holder to remove as much as can of the membranes.

 Bleeding to be controlled from the uterus with No. 2 chromic catgut. Or, the edges of
the tear to be clamped with several pairs of Green Armytage forceps. Bleeding also to
be controlled from her broad ligament temporarily with pressure from a pack. If she
has an extensive haematoma from the torn vessels on one side towards her kidney,
then evacuation to be done and must be tied them.

Repair or hysterectomy:

The indications depend on: (1) The nature and extent of the rupture. (2) surgeon’s
experience.

If surgeon is inexperienced and if repair seems very difficult then only hysterectomy is
performed. If the surgeon have some hysterectomy experience------

Factors favouring a repair are: (1) A rupture which is not too large. (2) A rupture with
clean edges which are easy to see and are not too oedematous. (3) Little or no infection.

Factors favouring a hysterectomy are: (1) Extensive or multiple tears. (2) Edges which are
very bruised and oedematous and not easy to define, especially some posterior ruptures, or
ruptures extending down into her vagina. (3) Gross infection of her uterus.

The repair of a ruptured uterus:

 Start at the apex of the tear; Suture it as for caesarean section, using 2 layers of
continuous catgut in a large half-circle round-bodied needle (size ''2' or ''3'). You can
suture a vertical tear going down to the cervix from below upwards. Traction on the
suture will help to bring the lower end into view. Make the second layer an inverting
continuous suture. If necessary, use extra sutures to close off the corners, or repair her
vagina (usually anteriorly).

Hysterectomy for a ruptured uterus:

Hysterectomy may be surprisingly easy when the tear is extensive and transverse, and the
uterus almost completely detached.

Indications
(1) Complicated rupture of the uterus.

(2) Postpartum haemorrhage, which is not responding to treatment, and when tying the
internal iliac arteries has failed to control bleeding.

Closing abdomen (after hysterectomy or repair):

 If the mother’s condition is unstable, abdomen to be closed without delay.

 If it is stable additional injuries to be search especially to her bladder.

 Peritoneum must be cleaned and washed with at least two litres of warm saline.

 1 g of tetracycline in 1000 ml of warm saline should be instilled.

 Abdominal wall must be closed as usual with No. 0 or 2/0 catgut.

Post operative monitoring:

 Haemoglobin level to be monitored.

 A catheter should be kept in bladder until her condition is satisfactory, and urine
output should be monitored carefully. It should be at least 1 ml/kg/hour.

 Watch for anuria, respiratory complications, peritonitis, and peritoneal abscesses.

 Nutritional requirement must be fulfilled; if there are no signs of peritonitis, start

feeding her orally with a high-energy high-protein mixture as soon as her bowel
function allows it, a few days after the operation. If there are no complications this
can usually start on the 3rd postoperative day.

Complications:

 Postoperative infection.
 Damage to ureter.
 Amniotic fluid embolus.
 Massive maternal haemorrhage and disseminated intravascular coagulation (DIC).
 Pituitary failure.

Prognosis:

 4.2% maternal mortality.

 46% perinatal mortality and morbidity.

Prevention:
Unfortunately, uterine rupture cannot be adequately predicted for women wanting a trial of
labour following a previous Caesarean section. Doctors should review the medical history for
risk factors and counsel regarding her relative risks, benefits, alternatives and probability of
success. Usually, shared care undertaken with an obstetrician is appropriate for any woman
with a previous section. The following guidelines are helpful to prevent the tragic occurrence
of rupture uterus:
 The at-risk mothers likely to rupture should have mandatory hospital delivery.
 General anaesthesia should not be used to give undue force in external version.
 Undue delay in the progress of labour should be viewed with concern.
 Judicious selection of cases with previous history of caesarean sections for vaginal
delivery.
 Judicious selection of cases regarding oxytocin infusion for induction or augmentation
of labour.
 Attempted forceps delivery or breech extraction through incompletely dilated cervix
should be avoided.
 Destructive vaginal operations should be performed by skilled personnel.
 Manual removal in morbid adherent placenta should be done by senior person.

Conclusion:
Rupture of the uterus is one of the most serious complications in midwifery and obstetrics. It
is often fatal for the fetus and may also be responsible for the death of the mother. It remains
a significant problem worldwide. With effective antenatal and intrapartum care some cases
may be avoided.

Bibliography:

1. Dutta DC. Textbook of obstetrics.7th edition (2011). New Central Book Agency
(P) Ltd. P 426-429.
2. Fraser DM, Cooper MA. Myles text book for midwives. 15th edition (2009).
Churchill livingstone. Edinburgh London. P 634-635.

3. Baskett TF (1999) Essential Management of Obstetric Emergencies 3rd edition

Clinical Press, Bristol.
4. Boyle M et al Emergencies around Childbirth a handbook for midwives Chapter 8
P92 (2002)
5. Park EH, Sachs BP (1999) Postpartum Haemorrhage and other problems of the
third stage. In:DK James, PJ Steer, CPWeiner and BG Gonik (Eds) High Risk
pregnancy management options (2e) WB Saunders, London
6. Kieser KE, Baskett TF; A 10-year population-based study of uterine rupture.
Obstet Gynecol. 2002 Oct;100(4):749-53.
7. Bujold E, Gauthier RJ; Neonatal morbidity associated with uterine rupture: what
are the risk factors? Am J Obstet Gynecol. 2002 Feb;186(2):311-4.
8. Grobman WA, Lai Y, Landon MB, et al; Prediction of uterine rupture associated
with attempted vaginal birth after cesarean delivery. Am J Obstet Gynecol. 2008
Apr 23.

PROTOCOL ON

MANAGEMENT OF RUPTURE UTERUS

 Submitted to
Madam Madhushri Roy
Senior lecturer
Govt college of nursing,Burdwan

Submitted by
Anupama Jash
Msc nursing student ,final year
Govt college of nursing Burdwan