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Rupture Uterus

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Rupture Uterus

Rare event

Incidence 0.3/1000 deliveries

Prompt diagnosis

Prompt treatment

Delayed diagnosis

Increasedmaternal mortality

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Action Plan

When to suspect?

Beware of fetal distress in association

with risk factor for uterine rupture

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Action Plan -- Maintenance of

AirwayAssess

Maintain patency

Oxygen 15 l/mt via tight fitting mask

Attach pulse oximeter

Call anaesthetistConsider tracheal intubation

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Action Plan -- Maintenance of

BreathingAssess

Ventilate

Protect airway

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Action Plan -- Maintenance of

CirculationAssess pulse and BP

CPR if necessary

Put on ECG and automatic BP monitorTreat periarrest arrythmias

Secure IV access using two large borecannulae

Send blood for FBC, cross match 6 units andclotting screen

Replace intravascular volume as necessary

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Action Plan

Call senior obstetrician

Obtain consent for laparotomy and

hysterectomy

Baby alive, cervix fully dilated

consider instrumental delivery

Perform urgent laparotomy under GA

Prophylactic antibiotics

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Type of operation is dictated by the size

and s ite of rup tu re, the degree of

haemorrhage and patients futurefer t i li ty w ishes

Document in detai ls, incident,

assessment, treatment andmanagement plan with date, time and

signature

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When to suspect ?

Suspectbeware of fetal d istressin

association with r isk factor fo r uter ine

ruptureSign

Commonest prolonged FHR deceleration(70%)

Pain and bleeding, unreliable (7.6% & 3.4%)

Cessat ion of uter ine act ionswith CTG evidence

of fetal distress

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Risk Factors

Previous CSesp if subjected to oxytocics

Previous uterine t rauma / su rgery

Oxytoc icusage in mult iparouspatientsMuller ian tract anomalies

Forceps deliveries esp Kiellands

Multipara with previous FTND and significantlarger baby or malposition in presentpregnancy when allowed a prolongedsecond stage

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Site of Rupture

Dehiscence of lower uterine segment in

cases of previous LSCS

Rupture may extend anteriorly towards backof bladder, laterally towards uterine arteries

or into broad ligament plexus of veinsPPH

Posterior rupture is associated usually with

uterine malformations. Also seen with post

CS, following obstructed labor and rotational

forceps deliveries

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Surgical Procedure

Sustained haemorrhage indication for

hysterectomy

Subtotal simpler and quicker besidesless risk for damage to bladder and

ureter

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RUPTURE UTERUS

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Bandls RingAlso known as Retraction Ring

Seen in Obstructed labor

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Pathological Retraction Ring

Gradual increase in intensity, duration andfrequency of uterine contractions

Phase of relaxation decreases

Ultimately tonic contraction sets in

Retraction continues

Lower segment thinned and stretched

Formation of circular groove between active

upper and distended lower segmentPronounced retractiondecreased flow at

placental sitefetal distress

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Progress of labor

Labor ceases in response to obstruction

because of uterine exhaustion

In multigravida retraction continues withprogressive thinning and dilatation of lower

segment and progressive elevation of

Bandls ring closer to umbilicusruptureof lower segment

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Clinical Features

Pain discomfort because of prolonged labor

Maternal exhaustion

Keto acidosisUpper segment hard and tender

Lower segment distended and tender

Ring appreciated running obliquely betweenumbilicus and symphysis pubisriseswith time

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Taut and tender round ligaments

Absent FHS usual

Dry vagina, offensive discharge

Cervix fully dilated

Cause of obstruction apparent

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Management

Condition preventable

Supportive treatment-

IV fluidsTreatment of keto acidosis

Sedation

Antibiotics

DefinitiveRelieve obstruction by safeprocedure after excluding uterine rupture