Multifetal multiple pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation Diagnosis is by ultrasonographic measurement of amniotic fluid. Maternal disorders contributing Failure to recognize labor dystocia with excessive uterine contractions against a lower uterine restriction ring.
If women who have had a prior cesarean delivery wish to try vaginal delivery, prostaglandins should not be used because they increase risk of uterine rupture. Symptoms and signs of uterine rupture include fetal bradycardia, variable decelerations, evidence of hypovolemia, loss of fetal station detected during cervical examination , and severe or constant abdominal pain.
If the fetus has been expelled from the uterus and is located within the peritoneal cavity, fetal and maternal morbidity and mortality increase significantly.
Treatment of uterine rupture is immediate laparotomy with cesarean delivery and, if necessary, hysterectomy. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world.
The Manual was first published in as a service to the community. Uterine ruptures occurring along the scar tissue from a prior C-section are generally less intense and result in less dramatic symptoms compared to a spontaneous rupture of an unscarred uterus. In fact, it is widely accepted in the medical community that a uterine scar and the use of uterotonic agents for induction are the most important risk factors identified for uterine rupture.
The classic first sign of a uterine rupture is often said to be abdominal pain, particularly when there is an epidural block in place. But many medical experts push back on the notion of abdominal pain as a symptom. Because abdominal pain is the hallmark of any normal labor. So, arguably, this symptom simply reflects partial pain relief by the epidural analgesic threshold of the epidural block. The fetal monitor can be helpful in picking up a concern about uterine rupture.
The fetal tracing may indicate that a uterine rupture is taking place. Prolonged deceleration of the fetal heart rate is the most consistent finding in cases of uterine rupture. The problem with clinically diagnosing uterine rupture is that these primary symptoms are often caused by other obstetrical complications or events.
When uterine rupture occurs during labor and delivery, there is an extremely short window of time for doctors to respond to avoid injury to the baby. This means there is no time to perform an ultrasound or any other diagnostic imaging scan or another diagnostic test.
Uterine rupture has to be diagnosed quickly based on clinical symptoms alone. Ultrasound imaging does have some application in evaluating the likelihood that scar tissue from a prior C-section will result in uterine rupture. The most important factors in the treatment and management of uterine rupture are a timely recognition and a presumptive diagnosis of the rupture; and b immediate intervention to deliver the baby as quickly as possible.
As soon as doctors even suspect uterine rupture, they must immediately stabilize the mother and then try to deliver the baby as fast as possible. According to various studies, once rupture of the uterus occurs doctors will only have between minutes to successfully respond to avoid serious fetal injury or death.
Intervention almost always involves an emergency C-section delivery. Once the baby is successfully delivered via C-section, doctors will need to surgically repair the mother's torn uterus. In some cases the uterine rupture may trigger major blood loss requiring doctors to perform an emergency hysterectomy removal of the uterus following the C-section. This is more likely when the uterus tear is longitudinal as opposed to transverse.
Sometimes, the solution to a developing uterine rupture is to turn off the Pitocin or Cervidil or another stimulant of uterine activity. Pitocin is used to expedite delivery. Overuse of Pitocin in labor is a well-known and documented cause of uterine ruptures. The package insert on Pitocin says as much. In a fifty-three year review of uterine ruptures and the and risk factors and causes of uterine ruptures, an article published in the American College of Obstetrics and Gynecologists concluded most uterine rupture cases are avoidable.
The article states the in the "majority of the cases Thus, the majority of cases must be viewed as potentially avoidable. Significant myomectomy. Any cause of uterine perforation. Prostaglandin E 1 misoprostol [Cytotec]. Prostaglandin E 2 dinoprostone [Cervidil]. Oxytocin Pitocin , especially high infusion rates. Information from references 2 through 4 , 7 , 11 , 15 , 21 , and 24 through Excessive uterine stimulation can cause rupture, and this has occurred with alkaloidal cocaine abuse. Misuse of oxytocin carries significant risks in any mother, and this risk may be increased during VBAC, especially at high infusion rates.
Recent VBAC studies have shown three to five times more ruptures among induced mothers compared with those having spontaneous onset of labor. While they were initially considered safe for use during VBAC, current reports describe ruptures in approximately 2. Timely management of uterine rupture depends on prompt detection. In the past, caregivers were taught to look for classic signs such as sudden tearing uterine pain, vaginal hemorrhage, cessation of uterine contractions, and regression of the fetus.
Results of one study of 99 ruptures showed that only 13 patients reported pain and only 11 had vaginal bleeding. Even ruptures monitored with an intrauterine pressure catheter IUPC often fail to show a loss of uterine tone or contractile pattern after uterine rupture.
Shoulder dystocia related to fetal parts lodging outside the uterus can also be a presenting sign. Figure 1 33 shows a tracing from a published case of uterine rupture. It should be noted that it differs little from tracings that might be seen in other cases of fetal distress—uterine contractions continue as measured by an IUPC , while fetal bradycardia develops. Information from references 3 , 13 , 15 , and 31 through Monitor tracing demonstrating fetal heart rate decelerations, increase in uterine tone, and continuation of uterine contractions in a patient with uterine rupture monitored with an intrauterine pressure catheter.
Uterine rupture: are intrauterine pressure catheters useful in the diagnosis? Am J Obstet Gynecol ; Do not waste time performing an ultrasound examination or counting instruments. In many such cases, you will find no uterine rupture, but in other cases, you will have saved a baby's life. Because the presenting signs of uterine rupture are often nonspecific, the initial management of uterine rupture will be the same as that for other causes of acute fetal distress.
Urgent delivery is indicated, which will typically mean a cesarean delivery. The physician should mobilize the hospital operating room team and, if necessary, call in the awaiting back-up surgeon. It is during surgery that a uterine rupture will be diagnosed and surgical correction initiated. On detection of this condition, the physician should ensure adequate intravenous access, arrange for sufficient blood transfusion, and call for a neonatal team to be ready for intensive-care newborn resuscitation.
In one study, best outcomes were noted when surgical delivery was accomplished within 17 minutes from the onset of fetal distress on electronic fetal heart rate monitors.
The life-threatening seriousness of uterine rupture is underscored by the fact that the maternal circulatory system delivers approximately mL of blood to the term uterus every minute. Neonatal outcome after uterine rupture depends largely on the speed with which surgical rescue is carried out.
Much of the published literature comes from large medical centers, where in-house physicians and support facilities are available for emergency surgery at any time. One large study's neonatal mortality rate was 2. Unfortunately uterine rupture cannot be adequately predicted among women desiring a trial of labor for VBAC, so constant preparedness is needed. In a patient with a known prior classic incision, repeat surgical delivery should be planned for before the point that spontaneous labor may be expected.
A standardized consent form should be available from physicians' malpractice carriers, although some fear the legal language might drive patients away from appropriate VBACs.
Physician immediately available throughout active labor, capable of monitoring labor and performing emergency cesarean delivery. Circumstances under which a trial of labor should not be attempted. Inability to perform emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff, or facility.
Information from ACOG practice bulletin. Vaginal birth after previous cesarean delivery. Clinical management guidelines for obstetrician-gynecologists.
American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet ;— During a trial of labor, continuous fetal heart rate monitoring is imperative because this can be the only indication of an impending rupture. Physicians are also advised to carefully review their hospital's resources for handling emergent complications such as uterine rupture.
Many family physicians rely on consultation from others for cesarean deliveries, which may delay surgery in emergency cases. An important aspect of prevention is arranging for and confirming prompt surgical back-up before emergencies such as uterine rupture occur, or referring a patient to a center where more intense care can be provided.
Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. Address correspondence to Kevin S. Toppenberg, M. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.
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