The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes336
EMQ1502
SBA2115
Do you realy want to delete this discussion?
Forum >>

ESSAY 179 - UTERINE RUPTURE

Posted by Srivas  P.
Rupture Uterus is an obstetric emergency with high maternal and perinatal morbidity and mortality. It is a recognized complication of induction of labor with previous caessarean section, with incidence of uterine rupture between 0.5-1.5 percent. The factors which can cause rupture uterus should be identified and steps should be taken to minimize the risks if possible.

A classical Caesarean is a contraindication to vaginal delivery. This woman must have had previous lower segment section to have been considered for induction of labor now. The incidence of normal vaginal delivery after previous section is 60 % and this woman should be given an option of vaginal delivery while taking all precautions avoid rupture uterus. If the woman has abnormal presentations like breech, obvious cephalo pelvic disproportion or a big baby she should not be induced. Labor should be carefully monitored and if the labor is slow with a suspicious fetal heart charting or with suspicion of CPD, early decision for LSCS must be taken. If the woman gives history of severe post operative infection following previous section, with possibility of a weak scar, induction should be avoided. As previous section was done for placenta praevia there is possibility of morbid adherence of placenta to the scar with likelihood of scar rupture. The placenta should be localized by USG and clear cleavage between uterus and placenta must be recorded to rule out placenta accreta, increta or percreta.

The induction should be done in the labor room with senior midwife in attendance and she should have continuous fetal monitoring. She must have pulse and B.P charting done to detect early signs of rupture uterus. Blood must be cross matched and kept ready. Injudicious use of syntocinon should be avoided to prevent hypertonicity of uterus. For the same reason multiple doses of prostaglandins should be avoided. If hypertonicity occurs the dose of Syntocinon should be decreased and intravenous ritodrine or terbutaline should be given to relax the uterus. Greater care should be taken with prostaglandin use, as once given the dose cannot be diluted though Intravenous ritodrine can be given to decrease the intensity of contractions. Ideally intrauterine catheters if available can help reduce hypertonicity.

The labor room staff must be conversant with early signs of scar dehiscence which includes maternal tachycardia, maybe haematuria, suprapubic bulge, scar tenderness, fetal heart rate changes like decelerations etc. Complete rupture of uterus is more dramatic with marked hypotension, feeble pulse, sudden pain abdomen followed by diminished or absent contractions, abdominal distension with shifting dullness, fetus lying outside uterus and easily palpable and uterus contracted and lying to one side, absent fetal heart and bleeding per vaginum.

Once rupture is suspected senior anesthetist, obstetrician, hematologist should be called. Two large I/V lines should be setup and 6 units of blood arranged. Consent should be taken and relatives should be explained about possibility of hysterectomy. At laprotomy further treatment depends upon nature of rupture, possibility of repair, future reproductive needs of the patient etc. If damage is extensive with no possibility of future pregnancy tubal ligation should be done after repairing the uterus. If uterus cannot be repaired due to extensive damage, hysterectomy should be done in maternal interests. If the scar rupture is linear and is on the lower uterine segment similar to a LSCS, it may be repaired and she may be given further option of vaginal delivery without induction of labor in next pregnancy. If the rupture extends to upper segment and can be repaired she must be told to have elective caesarean in next pregnancy at 36 weeks.

It is very important to give the woman and her partner proper counseling explaining chronology of events, the steps taken and she should be told about her future reproductive potential, risks involved, care needed etc. Incident report should be written and case sheets properly completed. The CTG should be kept in records.
Posted by Aroosha B.
The risk of rupture in a patient with a previous one scar is 0.25%. To minimize the risk of rupture the decision for induction should be taken at a consultant level. A quick review of her previous obstetric history including the parity, mode of delivery, any VBAC should be done as multi parity with previous scar is associated with increased risk of dehiscence. The method of induction of labor will be done by accessing her bishop score. The various methods are prostaglandins, amniotomy and oxytocin. How ever induction of labor with prostaglandins has been shown to significantly increase the risk of intrapartum scar dehiscence to as high as 24.6 per 1000. Induction of labor by amniotomy with axytocin administration is preferable as the risk of complication form this method of induction appears to be low. Continuous electronic fetal monitoring is to be done. Labour progress should be charted on a partogram and ideally a progressive smooth curve of cervical dilatation should be observed. Deviation from this pattern requires critically reappraisal with careful consideration of reason for slow progress and possibility of an obstructed labour contraindicating the use of oxytocin. High infusion rates to be avoided and low dose regimens adhering to the licensed max dose of 20 mu per min. syntocinon (UK) with a dose increment no more frequently than every 30 min should be done. The partogram should be reviewed carefully and a failure of smooth progress will require an early repeat caesarean section.
Uterine rupture during labor can be recognized by carefully monitoring cardiotocography, which may show reduced FHR variability and late decelerations, The patient may complain of sever pain at scar site. A rapid pulse and low BP are signs of intraperitoneal bleeding. On per abdomen examination there will be tenderness at scar site. Other ominous sign are palpable fetal parts outside the uterus. On per vaginal examination there will be fresh bleeding.
It is important to take swift action if the life of the mother and the baby are to be saved. Senior Obstetric and anesthetic help should immediately be summoned and the woman transferred to theater. Large bore intravenous access should be ensured and blood sent for cross matching. An immediate laprotmy should be undertaken and senior obstetric help summoned. Also Senior pediatric help to resuscitate the baby should be available. In case of stable patient with an uncomplicated rupture, surgical repair of the rupture site is acceptable. In this case it is advisable to perform an elective caesarean section in the next pregnancy at 36 weeks. In many cases caesarean hysterectomy is necessary to control bleeding. An important aspect of management is proper postnatal counseling and explanation of the events as often there is no time for detail discussion at the time of emergency and this often leave the patient. unsatisfied. This should be undertaken by the consultant in charge of the woman?s care.
Posted by adnan S.
Induction of labour in a women with previous caesarean section is consider as high risk,associated with risk of maternal morbidity and mortality due to scar dehiscence&rupture,which is around 0.5%-1% in lower segment c section which significantly increase if I O L done with prostaglandins as compare to IOL with ARM&oxytocin.There is increased risk of intrapartum fetal acidosis &fetal death.IOL should be done on delivery suit with 1:1 midwiefry care.
To minimize the risk of uterine rupture during labour .all the carers on labour wards must be trained in the identification of the signs & symptoms of scar rupture.Continues electronic fetal monitoring is performed once labour is established.There should be high level of surveillance &early recognition of signs of immenant rupture like prolonged variable deceleration or late deceleration on CTG,progress of labour should be carefully moniterd &early recognition of secondry arrest ,heamaturia,fresh small amount of vaginal bleeding.Scar dehiscence are usually asymptamatic and may only be appeard at the time of c section.General measures like Site intra venous access,which can be caped and flushed,group and save the blood.
Uterine rupture during labour is recognized by sudden fetal bradycardia, maternal hypotension ,tachycardia,sudden loss of contraction ,palpable fetal parts if the fetus is extruded in the abdomen ,on vaginal examination upword displacement of presenting part , &heavy vaginal bleeding. Once clinical diagnosis of rupture uterus made it becomes obstetric emergency,swift action is taken to save the life of mother &fetus.Call for senior obstetric,&aneasthetic help,and also senior peadiatric help to resuscitate the baby.at the same time ensure intravenous access with large bore canula contact heamatologist and inform the urgency of blood requird.Foleys catheter is inserted ,it helps to check urine output and to helplocalise blader neck at surgery.An immediate laprotomy is under taken ,in case patient is stable with un complicated rupture ,surgical repair of the rupture site is done.If the rupture of the lower segment extend anteriorly into the back of the bladder,or laterally in the region of uterine artery,or into broad ligament causing extensive heamorrhage ceasarean hysterectomy is necessary to control bleeding.Postnatal counseling is important with detailed explanation of situation to the is done by the consultant in charge of the womans care.In case of surgical repair of rupture site it is advisable to have an elective c section at 36 wks.Incidence report form is filled.
Posted by Sarwat F.
Various strategies to minimize the risk of uterine rupture during labour include maternal monitoring of blood pressure, pulse and vaginal bleeding, continuous CTG recording and avoiding hyper-stimulation of uterus. Her chart should be reviewed for the findings in previous caesarean section and any complications happened at that time for example tears to lower uterine segment following difficult extraction of fetal head. Any abnormalities in maternal vital signs should be considered seriously and there should be low threshold for diagnosis of uterine rupture. If the mother is having epidural, there may be no complain of severe abdominal pain and even without epidural strong pain of uterine rupture can be mistakenly diagnosed as labour pains. Palpation of abdominal scar to check for tenderness may provide a clue for possible scar dehiscence although this has not been confirmed in studies. Other clinical signs include uterus is felt hard and tender on abdominal palpation, normal rhythm of contraction and relaxation of uterine contractions are lost and in advanced cases fetus can be palpated separate from the uterus which is present as a mass alongside the fetus on abdominal palpation. Abnormalities in CTG should alert a diagnosis of possible uterine rupture. Syntocinon infusion should be titrated cautiously so that no more than 3 contractions lasting for upto 40 to 45 secs occur. Uterine relaxants in the form of subcutaneous terbutaline may be considered in cases of hyperstimulation. Women should have 2 units of blood crossmatched and readily available. IV access with wide bore cannula sould be maintained as soon as woman goes in labour. Senior obstetrician should be aware that a woman with previous caesarean section is in labour.
There is no definite diagnosis of uterine rupture and condition is usually evident retrospectively. With woman in labour with previous caesarean section, any abnormalities in maternal blood pressure and pulse, uterus hard, tender and not relaxing on abdominal palpation, fetal distress, vaginal bleeding, haematuria should be carefully evaluated and low threshold for diagnosis of uterine rupture is kept. Ruptured uterus is an obstetric emergency with high maternal and perinatal mortality rate. Management includes stabilization of maternal condition and laparotomy. Senior obstetrician, anaesthetist, paediatrician and midwife should be called, pressure infusion is started, oxygen is given, and woman is transferred to theatre. General anaesthesia is usually given but final decision will be by anaesthetist regarding mode of anaesthesia. Laparotomy is done either through previous scar or by midline incision. Baby is delivered as soon as possible and handed over to paediatrician. Any blood clots present in peritoneal cavity should be removed. Uterine tear is repaired and hysterectomy is reserved only in cases of extensive damage which cannot be repaired. Relatives of woman and in case woman is conscious should be counseled at each step of management. Peritoneal cavity is cleaned and lavage with saline is done. After surgery women should be transferred to HDU for monitoring. Blood transfusion and FFP may be required. Incident reporting is done. Anti D is given for Rhesus negative and kleihauer test is done. Woman will be counseled that she will need caesarean section in any future pregnancies.
Posted by Sreekala S.
A previous Caesarean section scar in the presence of an anterior placenta praevia runs a high risk of scar rupture during labour. Therefore, an ultrasound scan is recommended for this woman to rule out an anterior placenta. There is also a risk of having placenta praevia in this pregnancy as placenta praevia can be recurrent. Ultra sound scan is not routinely recommended to assess the scar integrity as it is difficult to predict scar rupture depending upon the ultrasound characteristics of the scar. MRI and colour flow Doppler should be considered in the presence of an anterior placenta to rule out a morbidly adherent placenta.
Careful patient selection is important in minimizing the risk of uterine rupture in the presence of a previous caesarean section. Twins and anterior placenta in the presence of a previous scar carry a high risk of scar rupture in labour and therefore it is recommended to be delivered by an elective section in the presence of experienced staff. A senior Obstetrician should be present during delivery. Informed consent should be taken after counselling for haemorrhage, transfusion and the possibility of hysterectomy. Sweeping of membranes should be considered as the first method of induction. If labour does not ensue, then induction of labour with amniotomy with or without oxytocin should be considered. There is a lower possibility of scar rupture with oxytocin when compared to Prostaglandins. Therefore, prostaglandins should be avoided., but can be given after a detailed counselling and the woman should be carefully monitored after administration. Uterine activity should be carefully monitored. Hyperstimulation should be avoided. In the event of hyperstimulation occurring, tocolysis with terbutaline should be considered. Continous electronic fetal monitoring is required.
Uterine rupture should be suspected if the woman complains of a sudden severe abdominal pain with or without fresh vaginal bleeding. But, the pain can be masked in the presence of an epidural analgesia. Maternal tachycardia, hypotension and sudden CTG abnormalities can occur. The fetal parts can be felt easily and superficial than before. Extreme abdominal tenderness over the lower segment can be present. Scar rupture should be suspected in the event of postpartum haemorrhage, severe abdominal pain or maternal collapse after vaginal delivery.
Uterine rupture is an emergency and immediate delivery by laparotomy should be undertaken. IV access with two large bore cannulae should be secured and blood sent FBC, coagulation profile and 6units of blood crossmatched. Oxygen(15lit/min) should be administered, IV fluids started and OT staff alerted. Consultant obstetrician ,Anaesthetist and the paediatric team should be involved.The rent in the uterus should be repaired if possible .,otherwise hysterectomy should be considered if the rupture is not amenable for suturing or in the presence of an uncontrollable bleeding. Haematologist should be involved and blood transfused if required.Postoperative management should be considered in the ITU. Detailed documentation should be done and the couple informed of the events postoperatively
Posted by BAHAA-Uddin BOR B.
Ruptured uterus is a recognized complication of induction of labour ,especially in women with previous Caesarean section . A previous lower segment caesarean section scar carries a 0.25-0.5%.
The first step to minimize the risk of rupture is to recognise the risk factors ot its occurrence ,and if possible ,I have to avoid them. These include hypertonicity/hypertonic contractions,malpresentations,feto-pelvic disproportion and the type of scar on the uterus.
A classical caesarean section will be considered a contraindication ,whereas a complicated previous caesarean section , especially where there was postoperative infection.All these informations must be reviewed from the recorded notes of the patient. Multiple prostaglandins are more likely to result in hypertonia and therefore a limit should be put on the number of vaginal prostaglandins pessary to be used.
Once the patient is in labour , I have to avoid the injudicious use of oxytocin will minimize the risk of overstimulation.This is can only be achieved by titrating the dose of oxytocin against carefully monitored uterine contractions Continuous electronic fetal monitoring will offer a better objective estimation of the frequency and duration of contractions. The progress of labour should be monitored and charted carefully and any early signs of obstruction or disproportion recognized and the induction should be abandoned for caesarean section.
If uterine rupture occurs before delivery ,signs and symptoms usually include abdominal pain ,vaginal bleeding ,maternal hypotension ,tachycardia, fetal heart rate abnormality and easy palpation of fetal parts through the abdominal wall as the fetus is patially or completely extruded from the uterus.
Once rupture is suspected , treatment is immediate resuscitation ,While senior Obstetrician input must be requsted at an early stage ( consultant level ),Anaesthetist , Haematologist , Two large-bore canulae should be inserted ,a full blood count , clotting studies and sample for cross-matching ( at least four units of blood ),Blood bank should be informed about the high chance of needing more blood /clotting factors., and fluid replacement should be started ., O-negative blood may be required.
Lparotomy should be performed by a consultant .Uterine rupture may be incomplete or complete , where rupture extends through all layers of uterne wall and serosa. The rupture of lower segment may extend anteriorly into the back of urinary bladder or towards the region of uterine artery causing extensive haemorrhage and damage. Simple repair if the lower uterine segment dehiscence is the findings., but prompt hysterectomy may be life-saving procedure., whether total or subtotal hysterectomy. The choice depending on the situation , if the risk to urinary bladder or ureter is grave , subtotal hysterectomy is preferable.
Posted by Zaibunnisa khan K.
Uterine rupture is a rare catastrophic obstetric complication associated with a high rate of maternal morbidity and perinatal mortality. The risk of uterine rupture is increased in women with planned vaginal birth to 35/10000compared to 12 /10000
With elective repeat caesarean section (C/S).The fetal risk is significant with10 fold increase in perinatal motality .
The risk can be minimized by proper selection of cases for vaginal birth after one previous C/S.The risk of rupture is more with classical or T incision of previous C/S therefore vaginal birth is contraindicated.Sponatenous labour is preferable as induction of labour is independent risk factor .Induction of labour with prostaglandins significantly increase the risk of scar dehiscence during labour .This risk can be reduced by inducing with amniotomy and oxytocin administration instead of prostaglandin and avoiding high dosage and multiple doses of prostaglandin .
Risk is more in case with previous history of postoperative infection , sepsis and previous emergency C/S for prolong or obstetric labour therefore previous case note should be reviewed before deciding induction .Senior obstetrician should be involved in decision making in all cases to minimize the risk of rupture uterus.Risk of uterine rupture increased with anterior placenta in previous C/S. This can be reduced by high resolution ultrasound to role out morbidly adherent placenta .
Delivery should be in a maternity unit with all facilities available for immediate C/S and blood transfusion services.Contnious electronic fetal monitoring should be recommended during labour for early detection of fetal heart rate abnormalities presaging the occurrence of uterine dehiscenc .Women and staff should be aware of that the risk of uterine rupture is increased when induction is induced with previous C/S.
During labour women should be monitored closely .Intarvenous( I/V)access should be sited and blood should be cross matched as there is risk of emergency C/S.
Progress of labour charted carefully on a partogram , ideally a progressive smooth curve of cervical dilation should be observed. Deviation from this should be critically reviewed the case.High infusion rates of syntocinon should be avoided and low dose regimens with maximum of 20mu/min syntocinon,with dose increment of no more than every 30 minute should be recommended .Risk of rupture is increased with
Diagnosis of uterin rupture or scar dehiscence is not straightforward .There should be low threshold for aboneding the induction in case of abnormal progress of labour or fetal heart abnormalities to minimize the uterine rupture .Variable deceleriation may occur prior to the onset of fetal bradycardia or other maternal symptoms but are non specific.Sudden loss of uterine contractions ,fresh vaginal bleeding ,abdominal tenderness on palpation and changes in uterine contour are all predictive of uterine rupture but do not always occur.Fetal part may be palpable superficially per abdomen and on vaginal examination loss of the presting part and in third stage sudden gush of blood after placental separation one could suspect uterine uterine rupture.
When uterine rupture is suspected immediate delivery by laparotomy should be undertaken as maternal and particularly fetal morbidity are influenced by how soon the delivery can be achieved. Two I/V line should be secured and 6 unit blood should be cross matched and I/V infusion should be started Senior obstetrician ,anaesthetist and experienced pediatric help should be called immediately .Haematologist should be informed about the emergency blood requirement.Catheter should be passed and retained . Patient and the family member should be briefed about the emergency and high risk consent should be obtained for hysterectomy and tubel ligation incase if required.Patient should be shifted to operation theater and immediate laparotomy should be performed .Delivery of the baby is the first priorty ,followed by assessment of the site and extent of the uterine rupture.Option will be repair of the scar ,repair with bilateral tubel ligation and hysterectomy .Simple Repair with bilateral tuble ligation should be performed in case the rupture site is repairable and if further child bearing is not desirable otherwise uterine scar is repaired and in future elective C/S at 37 weeks is advised.Hystrectomy may be required in case uterine rupture is unrepairable or uncontrolable haemorrage .In case rupture involved bladder or ureteric injury is suspected urologist should be involved .
All the events should be clearly documented and signed.Detail of the operative procedure should be written and its better to show the site of rupture with a diagram with operative notes.Cardiotocogram should be kept saved in the record .Postoperatively patient should be observed closely for febrile morbidy ,urine output need for blood transfusion and thromboprophylaxis.
Detail of the event and the operation performed should be explained and discussed later on to the patient and her partner by senior obstetricisn or incharge of the case when patient was fully recovered or before discharge from the hospital .Future planning for pregnancy and advise regarding elective C/S at 37 weeks shoud be discussed .Written information should be provided along with verbal explaination.Psychological support by social worker should be given.An appointment for the next visit with consultant obstetrician should be arranged.









Posted by hala M.
Uterine rupture UR is an emergency obstetric complication associated with a high foetal and maternal morbidity and mortality. Fortunately it is rare 0.3/1000 deliveries despite the rising caesarean section CS rate, the risk is increased 2-3 times in case of one previous CS and this risk is going to be further doubled in case of induction of labour IOL. Therefore every step should be taken in order to prevent, recognise and properly manage this life threatening condition.


To minimise the risk of UR in this case a careful review of this patient notes should be done with reference to her past obstetric history, previous operation notes, post operation recovery and the findings in the current pregnancy.

Considering that the decision of IOL was taken by a senior obstetrician and there was no contraindication for IOL in this case, these steps needed to minimise the risk of UR starts with informing the patient about the possible risks and the outcome of successful labour and delivery. The discussion points should be recorded in the notes.
The methods for IOL are artificial ruptures of membrane ARM and IVoxytocin; prostaglandin is associated with higher risk. The place should in labour ward with one to one care in order to monitor the progress of labour, foetal and maternal condition closely. CS should be performed when there is inadequate progress of labour, foetal/maternal compromise and CTG changes suggestive of imminent UR). Blood should be cross matched and kept for use and large pore IV line should be instated)
The staff awareness of the symptoms and signs of UR is paramount especially the CTG abnormalities associated with it.

The UR might be preceded by signs and symptoms of imminent UR such as the CTG changes (prolonged variable and delayed deceleration), haematuria, labour secondary arrest and small vaginal bleeding. These would be followed by foetal bradycardia, upward displacement of the presenting part, sudden loss of contractions, maternal hypotension and heavy bleeding.

When UR is identified/ suspected a team of senior Obstetrician, anaesthetist and haematologist should be involved and resuscitation measured taken and the transfer to theatre arranged. The patient and the family should be informed about the diagnosis and the possible management and its success. The possibility of hysterectomy should be discussed.

At laparotomy the management depends on the intra op findings. If the baby is still alive then the resuscitation can be done by the paediatrician. In case of limited small rupture then a conservative repair can be done. In case of heavy bleeding and extensive rupture the senior obstetrician might do hysterectomy.
All course of actions should be recorded neatly in the patient?s notes

After the operation the patient should be kept in a high dependency unit HDU until her condition is stabilised and the risk of DIC is no longer present. She and her family should be informed about the management she had and the future effect on reproduction and this needs to be recorded in the notes. Continuance counselling and emotional support is important.
A hospital incident form should be filled.
Posted by Srivas  P.
Dr Paul, if the rupture of uterus is along the previous scar, small, almost similar to a caessarean scar, is there no role of suturing this dehiscence/rupture of uterus with a possibility of allowing a vaginal delivery next time avoiding oxytocics/induction ? You believe it has to be a repeat section now? I would be grateful for your clarification. Thanks.
Posted by Aroosha B.
DEAR DR PAUL
THANK U VERY MUCH FOR YOUR VERY NICE ADVICE BUT I HAVE ONE QUESTION THATAS U SAID RUPTURE CAN ONLY BE DIAGNOSED AT LAPROTOMY BUT ONCE WE HAD A PATIENT SHE WAS RUPTURED UTERUS AND FETAL PARTS WERE PALPABLE CLINICALLY OUTSIDE UTERUS AND WE WERE 100 % SURE OF RUPTURE AND IT CAME OUT SO
SECONDLY THE MARKS U GIVE SHOULD WE HAVE TO MULTIPLY IT WITH 2
THANKS DR AROOSHA
Posted by Srivas  P.
Thanks Dr Paul. I understood what you are conveying. I had gone through these articles and was getting confusing opinion. Now what I deduce is that all women after previous 2 LSCS should be offered elective CS only. The risks involved does not warrant offer for vaginal delivery and the woman should be explained the higher maternal and fetal risks if she chooses to have vaginal delivery. Thanks a lot

1) Eur J Obstet Gynecol Reprod Biol. 2003 Sep 10; 110(1):16-9. Trial of labor after two or three previous caesarean sections
Conclusion : Elective repeat caesarean section is not the only answer to a woman with two or three previous caesarean sections. A trial of labor can be a safe option for a selected group of women.
2) Trial of vaginal delivery following three previous caesarean sections.
BJOG. 2002 Mar;109(3):350-1
3) http://www.obgyn.net/avtranscripts/paul_arulkumaran_part2.htm
4) http://www.obgyn.net/displayarticle.asp?page=/firstcontroversies/prague1999sinha-arulkumaran
Posted by Aroosha B.
Dear Dr. Paul,
thanks again. Regarding this question on uterine rupture, the question is that the woman has been counselled for induction at 42 weeks, as this is a nonrecurrent cause the patient with this indication will have high success rate. Nobody will induce a patient with previous scar and placenta previa. Even a previous scar with breech presentation is a contraindication for induction, although it is not an absolute contraindication. If a patient with previous scar and breech presentation request for induction. So in this question still we need to mention that i will look for plesenta previa and breech presentation.
Posted by Aroosha B.
Dear Dr. Paul,
thanks again. Regarding this question on uterine rupture, the question is that the woman has been counselled for induction at 42 weeks, as this is a nonrecurrent cause the patient with this indication will have high success rate. Nobody will induce a patient with previous scar and placenta previa. Even a previous scar with breech presentation is a contraindication for induction, although it is not an absolute contraindication. If a patient with previous scar and breech presentation request for induction. So in this question still we need to mention that i will look for plesenta previa and breech presentation.
Posted by Vaani M.
A detailed history including the indication for previous LSCS, type of scar, intraoperative and post operative period, previous livebirth, previous multiple caesereans should be enquired.

Examination of pulse, scar for tenderness, ultrasonogram report for identification of repeat placenta praevia, full blood count, and blood for crossmatching has to be sent.

The risk of rupture is increased with use of prostaglandins for induction which has to be avoided, oxytocins may be used cautiously. Induction has to be done in the labour room with adequate staff and senior availability at all time. Continuous electronic fetal monitoring is required in labour. Progress of labour has to watched with careful recording of partogram, watching for tachycardia, and scar tenderness, to identify early rupture. Previous classical caeserean would be an indication for repeat caeserean. Similarly previous multiple caesereans more than one, major degree of placenta praevia, anterior placenta praevia with suspected accreta would also be an indication for repeat caeserean.

Careful monitoring would help identify a rupture uterus, which would present with tachycardia, scar tendernes early, later on hypotension, intrauterine fetal death, vaginal bleeding, retraction of the fetal head, maternal shock may set in. Consultant has to be involved in managing a rupture uterus. Blood bank should be alerted and blood availability ensured. Patient has to be informed early about the possibility of rupture with induction and consent taken prior to induction in relation to her views. Under anaesthesia, laparotomy has to be performed immediately, with resuscitation of woman ongoing. A scar dehiscence could be repaired as a repeat caeserean. A posterior or a lateral tear may be difficult to repair and a hysterectomy would be required if repair is not possible or bleeding is uncontrollable involving any of the vessels or with development of a haematoma. Insertion of drain may be required. Antibiotic prophylaxis and thromboprophylaxis would be required.

Postoperatively the woman needs to be explained and counselled about her condition, the complication, the need and type for surgery done and future plans. She would require a repeat elective caeserean or a sterilisation if not done with repair of scar or a continued contraception depending on her wish. If she had a hysterectomy she would need hormone replacement therapy and know the associated benefit on the bone and its harmful effects on breast cancer and heart disease. Follow up appointment needs to be given at discharge.
Posted by BAHAA-Uddin BOR B.
Dear : Dr. PAUL
THANK YOU VERY MUCH FOR YOUR RESPECTABLE ADVICE.
Posted by M H.

Uterine rupture is a rare complication but it carries a high morbidity rate for both mum and baby. The risk of rupture for a vaginal birth after caesarean section is 50 in 10,000. The risk increases with both the use of oxytocin and prostaglandins.
In this lady, a history of previous vaginal birth and a favourable cervix would again favour her chances of a successful vaginal birth. Reinforce the information imparted during the earlier counselling session to ensure that the lady / couple clearly understand the risks and management process. Ensure that a birth plan documented clearly in the case notes. Prior to should commencement of any oxytocins in labour, it would be vital to ensure all other steps to optimise labour have been carried out. The decision to commence oxytocin should be done with consultation to the senior consultant obstetrician and the risks and benefits explained to the lady. The induction should preferable be carried out in a labour ward and this lady shold be monitored closely for signs of uterine rupture. All carers and staff in the labour ward should be trained to recognise the signs and symptoms of rupture and there should be a protocol in place to aid in the management.
Intrapartum vigilance should be high with involvement of experienced personnel. Venous access should be obtained prior to IOL and blood sent for group and save. Continuos electronic fetal heart intrapartum should be in place as foetal bradycardia may be a sign of imminent uterine rupture.
Per vaginal bleeding, worsening cardiotocograph (CTG) changes, haematuria and secondary arrest are all signs of imminent uterine rupture. The signs of a uterine rupture is sudden loss of contractions, pain perabdomen, maternal hypotension, foetal bradycardia upward displacement of presenting part. Foetal parts may be clearly palpated if already extruded into the abdomen.
This constitutes an obstetric emergency. A patent airway should be maintained and venous access obtained via 2 large bore cannulas. Blood should be taken and sent for cross match and a full blood count to check for anaemia. If the lady is hypotensive, fluid resuscitation should be initiated with crystalloid infusion while awaiting blood products to arrive. The operating theatre and the most experienced anaesthetist should be notified to prepare for emergency laparotomy. The most experienced obstetrician should be on hand to deliver this lady. A laparotomy should be urgently arranged for and to salvage the foetus, delivery within 10 minutes need to be accomplished. A neonatologist should be in attendance as usually, the foetus would be severely acidotic. The couple should also be adviced that a hysterectomy may be a possibility as a life saving procedure. A bed in the intensive care unit shuld be arranged for this lady and a haematologist alerted that there may be a possibility of massive transfusions for this lady in case of a post partum haemorrhage.
Post partum, the lady should be cared for in an intensive care setting if there had been massive blood loss. Prior to discharge, there should be disclosure of the events that lead up to the event, the intraoperative findings and surgical procedures done. If the couple has completed their family, they should be adviced for effective or permanent sterilisation. Should she choose to embark on a subsequent pregnancy, she should be adviced to present early for follow up and most probably be adviced for an elective caesaren section.
Posted by ASFASDF A.
Ruptured uterus can be avoided by preventing women with classical caesarean sections from labouring. IOL with amniotomy + oxytocinon is associated with 80 per 10000 uterine ruptures; prostin induction is associated with 240 per 10,000 uterine ruptures. IOL with prostin especially should be avoided where possible. Continuous electronic fetal monitering will allow (possible) discovery of uterine dehiscence and usually have dramatic abnormalities in frank rupture of the uterus. Use of a partogram and an action line, with 3hourly VE?s will allow for earlier detection of failure to progress. In the case of failure to progress, randomised trials comparing continuing observation vs oxytocinon have not been performed. Failure to progress requires complete review of history, examination and review of observations and CTG. Features of macrosomia, diabetes, physical signs such as haematuria, bleeding, pyrexia, moulding, caput and vulval oedema all indicate obstruction. Failure to progress in this context, should be discussed with a consultant and decision for augmentation should be made at that level. Delivery should be in a unit with rapid recourse to delivery. Delivery suite anaethatist and obstetric registrar should be aware of patient. Obtaining IV access and G&S/FBC at start of labour would speed up process of CS in event of rupture.
Physical signs of rupture may be pain, bleeding, intrapartum or postpartum collapse and haemorrhage.
Signs of rupture maybe loss of station, fetal parts felt per abdomen, CTG abnormalities, hypotension.
An obstetric emergency would require the specialist anaeathatist, consultant obstetrician, paediatrician to attend immediately. Likewise, porters, technicians, theatre nurses and delivery suite co-ordinaters need to know. A ?crash call? or ?777? would achieve this istantly. Appropriate ressuciation of the mother, maintaining airway, breathing, circulation + placing 2 large bore cannulae in the patient and xmatching 6 units of blood.
Immediate laparotomy should be performed, and the baby delivered and resuscitated. Whilst this is organised, opportunity exists to gain consent for laparotomy and possible hysterectomy. Staff members not involved in the laparotomy can inform family members of events as they happen.
At laparotomy the uterus may or may not be repairable. There may/may not be bladder/renal tract injury. Haemorrhage that is uncontrollable may require hysterectomy and the support if specialities (ie) vascular, interventional radiology, urology if bladder injury.
Drains should be placed supra and infra sheath. Consideration should be given to thromboprophlaxis with s/c heparir. This may be delayed if concerns re haemostasis or coagulopathy exist. Other measures such as TED?s, hydration should not be delayed.
The patient may breast feed assuming the baby has not perished. Contraception before discharge should be discussed, full counselling offered and a recommendation for specialist review in the next pregnancy, if she still has a uterus. A critical incident form should be filled, and the case reviewed in surgical morbidity meeting.