Uterine Rupture

In 2004, the American College of Obstetrics and Gynecology (ACOG) revised their 1999 guidelines for Vaginal Birth after Previous Cesarean Delivery (VBAC). There are more than 100,000 VBAC that are successful each year. However, the concerns regarding an unsuccessful VBAC are real. The effects of a failed VBAC can and does cause a family not only heartache but also substantial medical and lifestyle changes.

Over 1 million cesarean deliveries are performed each year. There was an attempt to promote VBAC’s in order to reduce the large amount of c-sections that were being performed yearly. However, reports of poor maternal and fetal outcomes have hindered those efforts. The complication that causes the most concern is uterine rupture.

Uterine rupture is described as a catastrophic tearing of the uterus into the abdominal cavity. Often the only sign for clinicians is sudden fetal bradycardia. Often women with uterine rupture do not present with abdominal pain or vaginal bleeding. Further, uterine contraction patterns are unreliable for detecting uterine rupture and in fact often appear normal.

The only intervention for uterine rupture is for rapid surgical delivery of the neonate followed by surgical intervention for the mother. True uterine rupture is typically distinguished from scar separation by the need for emergency surgical intervention. It is during surgery that uterine rupture will be diagnosed and surgical intervention initiated. Studies have noted that best outcomes for the neonates are when delivery occurs within 17 minute of fetal distress noted on fetal heart rate monitors.

During pregnancy there is a huge increase in the amount of blood that circulates to the uterus every minute. This is why there is such a large amount of not only blood loss but also a large amount of blood replacement needed for those who do experience a uterine rupture. Hysterectomy has been required in up to 23% of these cases in order to control maternal hemorrhage. Five percent of all maternal deaths each year occur as a result of this complication.

The neonatal outcome is largely correlated with the speed in which the delivery occurs. Outcomes seem to be the worst when the neonate is extruded from the uterine cavity to the peritoneal cavity prior to delivery. Management typically involves admission to a Neonatal Intensive Care Unit and intervention can include the need for mechanical ventilation. More severe cases can lead to fatal fetal asphyxia or long term neurological impairment.

References:
Toppenberg, K. and Block Jr., W. Uterine Rupture: What Family Physicians Need to Know. American Family Physician 2002; 66:823-8.

Neff, M. ACOG Releases Guidelines for Vaginal Birth after Cesarean Delivery American Family Physician 2004; 70:7

Enkin, M., Keirse, M.J.N.C., Nielson, J., Crowther C., Duley, L. Hodnett, E., and Hofmeyer J. A Guide to Effective Care in Pregnancy and Childbirth Oxford University Press, 2000.

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