The effect of uterine rupture on fetal heart rate patterns

Diagnosis and Management of Uterine Rupture in the Third Trimester of Pregnancy: A Case Series and Literature Review

BACKGROUND

 Uterine rupture is associated with clinically significant uterine bleeding, fetal distress, expulsion or protrusion of the fetus, placenta or both into the abdominal cavity requiring prompt cesarean delivery and uterine repair or hysterectomy. Previous cesarean section is the most common risk factor. The most consistent early indicator of it is the onset of prolonged and profound fetal bradycardia.

OBJECTIVE

In this study, we present six cases of uterine rupture highlighting risk factors, and challenges in diagnosis and management, along with a review of the literature.

METHOD

A retrospective case series identified eight cases during the five-year study period. All cases from January 1, 2018 to December 31, 2022 were reviewed. Cases with multiple previous cesarean sections were excluded.

RESULT

Six cases meeting the study criteria were included in our case series. Uterine rupture was a rare occurrence with a prevalence of nine in 31,315 births representing 0.03% of deliveries. No maternal mortality or need for hysterectomy occurred in our study. Fifty percent of uterine ruptures were associated with stillbirths. The most common risk factor was a previous cesarean section in 83.3%. The most common presenting sign was non-reassuring fetal status patterns in 66.6%. A single case had a silent rupture.

CONCLUSION

Signs and symptoms of uterine rupture are nonspecific making diagnosis challenging. Delay in definitive management causes significant fetal morbidity and mortality. For best outcomes, vaginal birth after a previous cesarean section needs close monitoring in appropriately prepared units with the ability to perform immediate cesarean delivery and provide advanced neonatal support.

Pregnancy after rupture of the pregnant uterus

Pregnant women managed by us after suture repairs for rupture of the pregnant uterus between 2006 and 2009 in Enugu, South-east Nigeria were reviewed. Five pregnancies were managed during the study period. Four had normal pregnancies. Three booked early in pregnancy and had repeat caesarean deliveries at 36 weeks' gestation. One booked at another private hospital but had emergency caesarean section at 38 weeks' gestation. The fourth woman had repeat rupture at 28 weeks' gestation, suture repair and bilateral tubal ligation. Four healthy babies were discharged home. There was no maternal death. The outcomes of pregnancies after rupture of the pregnant uterus are good. Suture repairs should be the method of choice whenever preservation of future fertility is necessary. The woman and her family must be counselled on the associated risks and the need for hospital delivery by elective caesarean section in the subsequent pregnancies before discharge.

VBAC: safety for the patient and the nurse

During the 1970s and 1980s, some women fought for the opportunity to deliver vaginally after a cesarean birth (VBAC). The American College of Obstetricians and Gynecologists initially supported VBAC for many low-risk women. Interventions increased and complications of VBAC were reported, however, and recommendations changed. VBAC should be performed in hospitals equipped to care for women at high risk. Nurses caring for patients undergoing VBAC should be able to recognize and respond to the signs and symptoms of uterine rupture, including the most common symptom, which is a nonreassuring fetal monitor tracing. Nurses also should be aware of the necessity for 24-hour blood banking, electronic fetal monitoring, on-site anesthesia coverage, and continuous presence of a surgeon.