Rupture of the uterus during childbirth

Rupture of the uterus is a violation of the integrity of the wall of her body in any department during pregnancy or in childbirth.

In the UK, uterine rupture is a rare complication (1: 1,500 births), especially compared to other countries (1: 100 in some regions of Africa). Maternal mortality at the same time is 5%, fetal mortality - 30%. In the UK, about 70% of cases of uterine rupture are caused by the inconsistency of scars from the previous cesarean section (postoperative scars from the incisions of the lower segment of the uterus are ruptured much less than those from classical corporal incisions). Other predisposing factors include complicated labor in multiparous, especially when using oxytocin; surgical interventions on the cervix in the anamnesis; births with high forceps, internal obstetric rotation and fetal extraction beyond the pelvic end.

[1], [2], [3], [4], [5]

Risk factors for uterine rupture

To the group of pregnant women, who can rupture the uterus during pregnancy and during labor, are:

• pregnant women with scar on the uterus, after surgery on the uterus (caesarean section, enucleation of myomatous nodes with suturing the bed, enucleation of knots with coagulation of the bed after endoscopic intervention, suturing of the uterus wall after perforation, tubectomy for intramural tubal pregnancy);
• pregnant women after numerous abortions, especially complicated by inflammatory processes of the uterus;
• mnogogozhavshie pregnant women;
• pregnant with a fruit with a large body weight;
• pregnant with a pathological insertion of the head (frontal, high straight);
• pregnant women with pathological position of the fetus (transverse, oblique);
• pregnant women with a narrow (narrow) pelvis;
• Pregnant women with a combination of the narrowed pelvis and a large mass of the fetus;
• pregnant women, who were prescribed funds that reduce the uterus (oxytocin, prostaglandins), in connection with the scar on the uterus against the background of morphological changes in the uterus wall and the whole fetal bladder, polyhydramnios, multiple pregnancies, previous numerous abortions, childbirth;
• pregnant women with anatomical changes in the cervix due to the occurrence of scars after diathermocoagulation, cryodestruction, plastic surgery;
• pregnant women with tumors of the uterus, which block the exit from the small pelvis. If in pregnant women with a scar on the uterus the birth ended through natural
• birthmarks, manual revision of the uterine cavity is mandatory for its integrity right after the discharge of the afterbirth. When revising the uterus, special attention is paid to examining the left side of the uterus, where the most frequent ruptures are seen in the manual examination of the uterine cavity.

Signs and symptoms of uterine rupture

In most women, the rupture of the uterus occurs during labor. Only occasionally a rupture can occur before childbirth (usually due to a divergence of scars from a previous cesarean section). At the same time, in some women there is a slight soreness and sensitivity over the uterus, while in others the pain is very strong. The intensity of bleeding from the vagina is also different. It can be even insignificant (if the main amount of blood is poured into the abdominal cavity). Other manifestations of uterine rupture are unexplained tachycardia and sudden development of shock in the mother, cessation of uterine contractions, disappearance of the presenting part from the pelvis and distress syndrome of the fetus. In the postpartum period, the uterine rupture is indicated by prolonged or persistent bleeding, despite the well-diminished uterus, the continuation of bleeding, despite the closure of cervical ruptures; about the rupture of the uterus should be considered if the mother suddenly develops a shock state.

Clinical symptoms of a threatening rupture of the uterus with a disparity between the fetus and the pelvis (clinically narrow pelvis) are excessive labor, insufficient relaxation of the uterus after a fistula, sharply painful contractions, maternal restlessness, persistence of pain between fights in the lower segment of the uterus, tenderness in palpation of the lower segment of the uterus, absence or excessive configuration of the fetal head, anomalies of insertion and presentation of the head (including posterior view of the occipital presentation), pr the early discharge of amniotic fluid, the growth of anhydrous interval, unproductive powerful activity with full or approximate full opening of the uterine throat, involuntary attempts against the background of the highly located fetal head, edema of the cervix, vagina and external genitalia, a birth tumor on the head of the fetus, which gradually fills the cavity of the small pelvis, obstructed urination; with prolonged delivery, the appearance of blood in the urine; uterus in the form of an hourglass, deterioration of the fetus, spotting from the uterine cavity, a positive symptom of Genkel-Wasten.

Histopathic ruptures of the uterus are distinguished by the absence of clear symptoms, a "silent" course. The clinical symptoms of a threatening rupture of the uterus against the background of morphological changes in the myometrium (histopathic) include the pathological preliminar period, the weakness of labor, the lack of rhythm-stimulating effect, excessive labor after weakness of the ancestral forces in response to narodostimulating therapy, a possible pain syndrome, the appearance of permanent pain and local soreness after the contraction in the cicatrix on the uterus, or the lower segment, the pain of a permanent nature of unclear localization after cramping and radiating in the rump, premature, early rupture of membranes, intrapartum infection (chorioamnionitis, endomyometritis) intrapartum hypoxia, fetal death.

The clinical symptoms of a uterine rupture are the cessation of labor, the change of contours and the shape of the uterus, pain syndrome (pain of a diverse nature: aching, cramping in the lower abdomen and sacrum, severe pain that occurs at the height of the effort, against prolonged unproductive attempts at full opening of the uterine throat, when the position of the body changes, the pain in the abdomen opens, the pain in the epigastric region when the uterus ruptures in the part of the bottom, which is often accompanied by nausea and vomiting). 

During abdominal palpation there is a sharp general and local soreness; abdominal cavity (palpation of its parts through the abdominal wall), symptoms of irritation of the peritoneum, external, internal or combined bleeding, the growing symptoms of hemorrhagic shock, intrauterine fetal death.

Among the symptoms of uterine rupture, which is diagnosed in the early postpartum period, bleeding from the birth canal is isolated, no signs of placenta separation, severe tenderness of all areas of the abdomen, severe pain in the palpation of the uterus, abdomen, nausea, vomiting, a symptom of the occluded uterine fundus, symptoms of hemorrhagic shock of different degree. When palpation on the edge of the uterus, the formation (hematoma) is determined. There is hyperthermia.

Classification of uterine ruptures

1. By pathogenesis:

Spontaneous rupture of the uterus:

• with morphological changes in myometrium;
• with a mechanical obstruction to the birth of the fetus;
• when combined morphological changes in the myometrium and mechanical obstruction to the birth of the fetus. 

Forced rupture of the uterus:

• clean (with vaginal delivery, external trauma);
• mixed (with different combinations of rough intervention, morphological changes in the myometrium and mechanical obstruction to the birth of the fetus).

2. According to the clinical course:

• Risk of rupture of the uterus.
• Threatening rupture of the uterus.
• Rupture of the uterus, which took place.

3. By the nature of the damage:

• Incomplete rupture of the uterus (not penetrating the abdominal cavity).
• Full rupture of the uterus (penetrating the abdominal cavity).

4. By localization:

Rupture in the lower segment of the uterus:

• rupturing the front wall;
• lateral break;
• back wall break
• separation of the uterus from the vaginal vaults.

A rupture in the body of the uterus.

• rupturing the front wall;
• rupture of the back wall

Breaking the bottom of the uterus.

[6], [7]

Tactics of management at rupture of a uterus at sorts or labors

If there is a suspicion of rupture of the uterus during labor, laparotomy should be performed, the child should be removed by caesarean section, and the uterus should be subjected to revision during this operation.

Establish an intravenous infusion of the mother. The shock condition is eliminated by urgent blood transfusion (6 packets). Prepare for laparotomy. The decision on the type of operation to be performed is made by the senior obstetrician; if the gap is small, suturing may be performed (possibly with a simultaneous ligation of the fallopian tubes); if a rupture affects the cervix or vagina, you may need a hysterectomy. During the operation, with special care, it is required to identify the ureters, so as not to stitch or not ligate them. After surgery, prescribe antibiotics, for example ampicillin, 500 mg every 6 hours intravenously and netilmicin, 150 mg every 12 hours intravenously (if the patient does not have kidney pathology).

Pregnant women at risk in the course of monitoring the course of pregnancy develop a plan for delivery (may change during observation) and in the period up to 38-39 weeks. Pregnancy, a decision is made regarding the mode of delivery (abdominal or natural birth canal).

When histopathic changes in the myometrium (scar on the uterus) through the natural birth can give birth to women who have readings that were in the first caesarean section, do not repeat; in the history of one cesarean section, the previous cesarean section was performed in the lower segment of the uterus, the preceding births - through the natural birth canal; normal occipital presentation of the fetus; when palpation through the anterior vaginal arch, the segment of the lower segment is uniform and painless; when ultrasound is performed, the lower segment is V-shaped and thicker than 4 mm, echoconduc- tivity is the same as in other parts of the myometrium; there is the possibility of urgent operative delivery in the event of complications, birth monitoring is possible; consent to the delivery through natural birth canals has been obtained.

Labor in such cases is carried out under close supervision of the status of the parturient woman (symptoms of a threatening rupture with histopathic changes in the myometrium).

In women with anatomical and functional infertility of the uterine scar, delivery is performed by cesarean section at the 40th week with mature birthmarks.

Symptoms of anatomical and functional inferiority of the rumen include: pain in the segment of the lower segment, pain during palpation of the lower segment through the anterior vaginal fornix, its heterogeneity in ultrasound (thickness of the lower segment is less than 4 mm, different sound conductivity and thickness, balloon-like shape). 

At pregnant women from group of risk concerning rupture of a uterus in sorts careful supervision over development of patrimonial activity and a status of a fruit is spent. In case of complications, the tactics of labor management is revised in favor of surgical delivery.

If there are signs of a threatening rupture of the uterus, it is necessary to stop the labor activity (tocolytics, narcotic or non-narcotic analgesics), transport the pregnant woman to the operating room, immediately complete labor in the operative way (possibly delivery through the natural birth canal with fetal presentation in the plane of the narrow part or exit from the pelvis) .

A special caesarean section in such cases is the excretion of the uterus from the cavity of the small pelvis for a detailed audit of the integrity of its walls.

Treatment of the rupture of the uterus, which took place, is as follows; the mother is immediately transported to the operating room; if the condition of a woman is very difficult, the operating situation unfolds in the ancestral hall; urgently carry out anti-shock therapy with mobilization of the central veins, perform laparotomy and intervention adequate to trauma. Revision of the pelvic organs and abdominal cavity, drainage of the abdominal cavity, provide infusion-transfusion therapy adequate for the size of blood loss and correction of hemocoagulation disorders.

Surgery is performed in the following amount of suturing the rupture, over vaginal amputation or extirpation of the uterus with fallopian tubes or without them. The amount of intervention depends on the size and localization of the discontinuity. Signs of infection, the duration of the period after the rupture, the level of blood loss, the condition of a woman.

Indications for organ-preserving surgery are incomplete rupture of the uterus, a small full rupture, a linear rupture with clear edges, no signs of infection, a non-prolonged anhydrous gap, a preserved contractile function of the uterus.

Indications for supravaginal amputation of the uterus are fresh ruptures of her body with uneven crushed edges, moderate blood loss without signs of DIC syndrome and infection.

Extirpation of the uterus is carried out in the presence of a rupture of its body or lower segment, which passed to the neck with crushed edges, traumas of the vascular bundle, rupture of the cervix with a transition to its body, and also in case it is impossible to determine the lower angle of the wound.

In the manifestations of chorioamnionitis, endometritis, the presence of chronic infection, magpies are extirpated along with the fallopian tubes.

In all cases of surgical treatment for a uterine rupture or cesarean section for a threatening uterine rupture, the abdominal cavity is drained. At the end of the operation, a revision of the bladder, intestines, and ureters is mandatory.

If there is a suspicion of a bladder injury, 200 ml of a contrast solution is injected into the wound to determine its entry into the wound, controlling the amount of the solution removed from it (with a total bladder of 200 ml).

If there is a suspicion of a ureteral injury, methylene blue is injected intravenously and monitored by entering the abdominal cavity or bladder by cystoscopy.

In case of massive blood loss, ligation of internal iliac arteries is performed. In case of large trauma and significant blood loss, the ligation of the internal iliac arteries is performed before the main volume of the operation is commenced.

In the absence of an experienced specialist who can perform ligation of the internal iliac arteries, and the necessary operation for this time begin with the termination of the main vessels along the rib of the uterus.

Drainage of the abdominal cavity is carried out through the hole in the posterior arch of the uterus after its extirpation and through the contra-structures at the level of the ileum, with the formation of retroperitoneal hematomas, with the peritoneum over them not sewn,

In the postoperative period, anti-shock, infusion-transfusion, antibacterial therapy and prevention of thromboembolic complications are carried out.