Uterine rupture before or during labor is often a catastrophic complication of pregnancy. Although its occurrence is rare, it is associated with a high incidence of fetal and maternal morbidity and mortality. Uterine rupture involves the separation of the full thickness uterine wall and is associated with significant bleeding and consequential fetal distress. Uterine rupture should be differentiated from uterine dehiscence in which a preexisting uterine scar (cesarean section, myomectomy) gets separated but the overlying peritoneum remains intact and rarely bleeds significantly.
Risk factors that are known to increase the appearance of uterine rupture include:
Number of previous cesarean sections
Type of previous cesarean sections
Previous uterine myomectomy
Congenital uterine anomalies
Grand multiparity (greater than 5 pregnancies)
For a long time, the practice used to be ‘Once a cesarean, always a cesarean’. Repeat cesarean sections represented the majority of operative deliveries. Repeat cesarean sections were planned in advance of the expected date of confinement in order to preempt uterine dehiscence/rupture. Within the last 25 years, in an attempt to reduce the ever increasing number of cesarean sections, VBAC (vaginal birth after cesarean delivery) gained in popularity. This was also accompanied by an increased use of oxytocin (Pitocin) to accomplish a vaginal birth. The use of oxytocin (Pitocin) to augment or induce labor appears to have an increased risk of uterine rupture particularly in women who had a previous cesarean section.
Previous myomectomy (removal of fibroids) is usually associated with uterine rupture during the third trimester of pregnancy. Women who had a prior cesarean section because of a myomectomy are at an increased risk of uterine rupture in future pregnancies. The risk of uterine rupture is further increased when a fetus weighs more than 4,000 grams
Not all prior cesarean sections have the same risk of subsequent uterine rupture. A prior ‘classical cesarean’ or ‘low vertical cesarean’ involves a uterine incision that is placed vertically on the anterior uterine wall. At the present time, these types of uterine incisions for cesarean deliveries is rarely performed in the United States. The vast majority of cesarean sections in the United States involve the use of a ‘low transverse cesarean’ which places an horizontal incision in the anterior lower uterine segment. Women with 2 or more prior cesarean sections are even at a greater risk of uterine rupture in future pregnancies.
Although the risk of uterine rupture associated with a low transverse uterine cesarean is lower than with a classical uterine incision, it is still a risk factor that must be taken into account. The mode of labor and delivery following a cesarean section also influences the risk of a uterine rupture. Labor augmentation with oxytocin (Pitocin) is associated with a 4 fold increase in uterine rupture. Use of oxytocin (Pitocin) to induce labor is associated with a 12 fold increase in uterine rupture.
Classic signs and symptoms associated with a uterine rupture include:
Diminished uterine baseline pressure
Loss of uterine contractility
Recession of the presenting fetal head
Changes in the fetal heart rate are often the first signs of uterine disruption. Fetal bradycardia, prolonged late decelerations and recurrent variable decelerations are the most common findings associated with uterine rupture. If the placenta is extruded from the uterine cavity, a sudden appearance of a prolonged deceleration without recovery is the presenting picture. The sudden appearance of abdominal pain in a woman experiencing a prolonged fetal heart deceleration is highly suggestive of a uterine abnormality.
The urgency associated with a uterine rupture and sudden appearance of irreversible detrimental changes to mother and fetus do not allow for extensive confirmatory testing to be carried out. Diagnosis and treatment are usually based on signs, symptoms, and clinical interpretation. Treatment requires a timely diagnosis and immediate operative surgical delivery.
Morbidity and mortality associated with uterine rupture affects mother and fetus alike. Fetal consequences include:
Fetal hypoxia or anoxia
Fetal or neonatal death
Maternal complications associated with uterine rupture include:
Severe maternal blood loss
Need for hysterectomy
Medical providers are responsible for the diagnosis and management of complications that arise during the third stage of labor. If you believe that you, your child or your loved one have been misdiagnosed, are victims of a uterine rupture or wrongly treated and suspect the postpartum complications may be the result of a medical provider’s error that was diagnosable, avoidable and/or preventable, you may have a valid cause of action. The injury may be the result of a medical provider's mistake in handling your condition and the result of medical negligence. Dr. Borten has over 35 years of experience as an obstetrician and gynecologic surgeon to fully evaluate the merits of your potential case. Allow the Boston area medical malpractice attorneys at Gorovitz & Borten help you assert your rights and get the compensation you deserve.
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