A Study On Rupture uterus In Women with Previous Caesarean Sections
BY : DR. FARHAT MAZHARI
Uterine rupture is an uncommon but potentially
catastrophic outcome of pregnancy where the integrity of
myometrial wall is breached.
Ruptured uterus still remains one of the serious causes of
maternal and perinatal mortality and morbidity.
Since 1916, the time of Edward Cragin’s famous quote,
“Once a caesarean,always a caesarean”, the medical
profession has been concerned about the risks of
catastrophic uterine rupture in women with previous
In the past 20 yrs, VBAC has been encouraged but recent
studies reporting an increased incidence of uterine rupture
and perinatal mortality.
Has stirred controversy about the safety of VBAC.
Subsequently there has been an increase in the rate of
The rate of caesarean delivery has increased from 5% in
1970 to 26% in 1993 .( J Okla state med Assoc,1997)
The incidence of scar rupture in low transverse incision is
0.2-1.5% ,and 4-9% in classical scar.
The incidence is increasing due to increased incidence of
primary caesarean deliveries.
Uterine rupture leads to maternal mortality upto 1-13 %
and perinatal mortality of 74 - 92 % .
Lack of health information, illiteracy, poor ANC,home
deliveries by traditional birth attendants, uncontrolled
fertility contribute to uterine rupture.
Total and Primary Caesarean delivery
rates and VBAC rates
Types of Prior Uterine Incisions and
Estimated Risks for Uterine Rupture
ESTIMATED RUPTURE RATE
0.2 – 1.5 %
( data from ACOG 1999,2004 ; MARTIN 1997, REYES 1971 )
National guidelines and large reviews quote different
risks of uterine rupture in previous caesarean sections:
WHO ( 2005 ) – 1.0 %
ACOG ( 2010) – 0.5% - 0.9%
The objective of my study was to determine the
incidence , the risk factors and fetomaternal outcome
of uterine rupture in women with previous caesarean
This study was conducted over a period of six months from
January 2013 to June 2013 at Deptt. Of Obstetrics &
Gynaecology , PMCH.
The cases were selected from the patients attending to
Labour Room Emergency.
All cases of ruptured uterus who were either admitted with
or who developed this complication in hospital were
included in the study.
Diagnosis was made on history and examination and was
confirmed on laparotomy.
The cases were analysed with regard to their past
history, clinical presentation, management and outcome.
Total no of deliveries during this period was 3261 of
which 54 were cases of uterine rupture with frequency
of 1.6 % .
Previous caesarean sections was the leading cause of
ruptured uteri in 32 cases ( 59.3 % ). Total no. of patients
with prior caesarean deliveries during this period was
1682 .So, the incidence of scar rupture comes out to be
1.9 % ( 32 / 1682 ).
Cases with prolonged obstructed labour was the second
most common cause in 16 cases ( 29.6 %) ,where 60 %
patients gave history of injudicious use of oxytocin in
Cases with one caesarean section in past were 24 (44.4%)
,with two sections were 7 ( 12.9%), and one had previous
three sections ( 1.8 % ).
Lower uterine segment was the most common site of
rupture in 38 cases ( 70.8 % ).
Majority of women arrived in state of shock and required
urgent resuscitative measures.
Maternal deaths occurred in 7 cases ( 49 %) and perinatal
mortality was 49 ( 90.7%), live birth rate being 9.3%.
Hysterectomy was performed in 16 ( 29%) cases.
• Uterine rupture is typically classified as either :
COMPLETE : When all layers of the uterine wall are
INCOMPLETE : When the uterine muscle is separated
but visceral peritoneum is intact.
• Incomplete rupture is also commonly referred to as
uterine dehiscence .
• The greatest risk factor for either form of rupture is
prior caesarean delivery ( ref: ACOG 1999,2004 )
• UTERINE RUPTURE may be classified based on the
predisposing factors into the following :
RUPTURE OF PREVIOUS SCAR
TRAUMATIC RUPTURE OF UNSCARRED UTERUS
External cephalic version
SPONTANEOUS RUPTURE of UNSCARRED
UTERUS with UNDERLYING PATHOLOGY
Curettage with or without perforation
SPONTANEOUS RUPTURE OF UNSCARRED
Multiparae : uterus is weakened by rapid and
repeated childbearing.Induction of labour in such
patients calls for great caution.
The commonest cause is a previous caesarean section scar,
the Classical or the T-shaped incision is more likely to give
way in subsequent pregnancy than the low transverse scar.
An inter-delivery interval less than 18 months increases the
risk of rupture.
Any h/o of fever following caesarean raises serious doubts
about the integrity of scar.
Single layer uterine closure increases the risk.
Induction of labour with oxytocin in patients with previous
caesarean, has increased rates of rupture.
VERSION IN LABOUR specially internal cephalic is a
common cause of uterine rupture.
Instrumental delivery like forceps or ventouse application
through an incompletely dilated cervix may cause a tear of
cervix that extends upwards into the lower uterine
Occasionally rupture occurs at the very end of second
stage when ‘shortening of cord ‘ occurs due to extrusion of
placenta into the abdominal cavity.
Uterine rupture may present with primary PPH, that is
either concealed intra-abdominally or revealed.
Pathologic retraction ring occurs, strong uterine contractions
w/o cervical dilatation
Rupturing of endometrium,
myometrium and perimetrium
Uterine contraction stops
Rupturing of endometrium
Bleeding into peritoneal cavity
Bleeding into the vagina
Decreased blood volume, decreased
cardiac output , decreased BP
Increased gas exchange ,increased
Vasoconstriction of peripheral vessels,
increased heart rate , Increased Pulse
Uterine perfusion is decreased
Decreased perfusion of brain & kidney
Decreased LOC , Renal failure
Death of mother and fetus
SCAR RUPTURE: The patient with prior classical or
hysterotomy scar ,complains of a dull aching pain
with slight vaginal bleeding .Onset is usually
acute,with varying degrees of tenderness and
shock.FHS may be absent.
The onset is insidious in lower segment scar
rupture, a rise in pulse may be a hint..hence called
Silent rupture .the sign is therefore highly
significant during labour in women with previous
OBSTRUCTED LABOUR : The patient classically presents
with severe pain due to uterine contractions . Patient is
dehydrated ,Bandle’s ring formation is seen, the
presenting part is jammed in pelvis .
There is a sense of something ‘giving way’ or ‘ripped’ at
the height of uterine contraction.
The contractions may cease ,superficial fetal parts are
palpable with abnormal fetal heart rate pattern or absent
FHS. A characteristic sign is the loss of presenting part
from its former position on P/V exmn..features of shock
& vaginal bleeding is associated.
Diagramatic representation to show
In cases of complete rupture ,the retracted uterus
forms a firm swelling to one side of fetus , while in
incomplete rupture the bulge of a broad ligament
hematoma can often be felt to one side of uterus .
In cases of grand multiparae , the patient at the
height of uterine contraction is suddenly seized with
an agonising bursting pain followed by relief,and
cessation of contractions. Features of shock
,tenderness and varying amount of vaginal bleeding
is associated .
The Most common and maybe the first sign of uterine
rupture is a nonreassuring fetal heart rate pattern with
variable decelerations that may evolve into late
decelerations , bradycardia and death.
So,all women with previous caesarean should have CTG
monitoring during labour. And if there is any evidence of
abnormal fetal heart rate patterns,delivery should be
In the presence of CTG abnormalities, some have an
opinion for fetal blood sampling to detect hypoxia ;
however this procedure may incure a delay as we have a
maximum time of 30 min before which if we perform
surgery , we can save the baby .
USG plays an important role in the prenatal
examination of a patient with previous caesarean
section and to diagnose old ruptures .
The use of USG to evaluate the scar thickness from
previous caesarean helps to forewarn this potential risk.
The Montreal study suggested that the combination of
single layer closure and full lower uterine segment
thickness < 2.3 mm increases the chances of rupture.
UTERINE SCAR DEFECT
Arrow indicates a dehiscent myometrium
Initial management consists of resuscitative measures
i.e. Management of shock.
Counselling and support to the patient and her
attendants , inform them about the situation , the
surgery and maternal and fetal probable outcomes.
HYSTERECTOMY - usually subtotal , best course in extensive
REPAIR OF RUPTURE : in scar rupture where margin is clean.
REPAIR OF RUPTURE AND TUBAL LIGATION.
This study concluded that previous caesarean sections is
the major cause of uterine rupture in the present day
scenario ,followed by obstructed labour as the second
most common cause.
There is lack of awareness among rural population
regarding proper antenatal care and risks of VBAC .
Counselling regarding contraception , like PPIUCD
insertion is a good option to prevent such casualties.
About 75% patients in my study belonged to rural and
distant areas, so updating of primary health care
providers and stronger referral systems should be
stressed upon .
ATTEMPTED VAGINAL BIRTH AFTER CAESAREAN SECTIONS.
A strict criteria to indicate primary caesarean sections.
Patients who wish to ; and have a favourable condition
should be offered TOL (trial of labour) for VBAC , but
under strict vigilance.
Contraceptive counselling is a must beginning right from
the antenatal care , intranatal ( specially for PPIUCD) and
All patients with primary caesarean sections MUST have
institutional deliveries .
Perhaps we could suggest the inclusion of ‘ minimum
three ANC records ‘ as a criteria for provision of benefits
under JANANI SURAKSHA YOJNA ,so that more women
come for ANC and institutional deliveries.
Referrel systems should be strengthened ...
Primary health care providers should go a special training
to deal with patients with previous caesarean deliveries
and to identify the imminent signs of rupture so that they
can be referred at the earliest .
What We Aim For : A HEALTHY
MOTHER & A SMILING BABY