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The incidence of uterine
rupture is 0.05% of all pregnancies ( 1),
occurring between 1 in 140 to 300 of women with a
pre-existing scar (2).
The risk increases with the number of caesarean sections;
two previous sections carry a 3 to 5 fold risk over
one previous section (3,4).
The perinatal mortality is ten times that of the
maternal mortality (1).
CESDI established a focus group to report on the
42 cases in 1994-5 which resulted in an intrapartum
death. Although 93% of these cases had impending warning
signs, 57% had the diagnosis made only at the time
of laparotomy. 75% of the cases were deemed to have grade
3 suboptimal care (significantly more than the
other deaths in the enquiries).
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CESDI (5th Annual Report) - Recommendations
Women with a uterine scar require:
- Antenatal management including plans for
delivery and induction involving a documented
discussion with anexperienced obstetrician
(ideally a consultant but at least SPR4 or
higher).
- Attentive intrapartum fetal and maternal
surveillance in a setting where the baby can
be delivered within 30 minutes.
- Involvement of an experienced obstetrician
in intrapartum decisions.
- No more than one dose of prostaglandin unless
great vigilance is exercised.
- Information about relevant symptoms to be
reported to those caring for them in labour.
Hospital units need to provide:
- Local guidelines regarding the setting and
standards of labour.
- Local guidelines regarding the setting and
standards of intrapartum fetal and maternal
surveillance in women with uterine scar.
- Whenever uterine rupture occurs it should
be the subject of a departmental case review.
Training issues:
- All involved in intrapartum care of women
must be aware of the factors that may lead
to uterine rupture. In particular, they must
recognize that women with a uterine scar are
'high risk' and should be managed appropriately.
- All involved in intrapartum care of women
should undergo training in the use and interpretation
of CTGs.
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According to representatives of units in the West
Midlands who attended this Forum, 44% of maternity
units do not have fire drills on their labour suite
on a regular basis.
Suggested management of uterine rupture:
- Stop oxytocinon
- Call key personnel, haematologist, porter
- Bloods, IV access & fluids (16 gauge venflon)
- Continuous monitoring
- Rapid delivery
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References:
1. Lynch JC. Uterine rupture and scar dehiscence.
A five year survey. Anaesth Intens Care 1996;24:699-704, Abstract
2. CESDI 5th Annual Report published by the Maternal and Child Health Research
Consortium in May 1998.
3. Miller D. Vaginal birth after cesarian: a 10 year experience. Obstet Gynecol
1994;84:255-8, Abstract
4. Caughey AB. Rate of uterine rupture during a trial of labor in women with
one or two prior cesarian sections. Am J Obstet Gynecol 1999;181:872-6, Abstract
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