Rupture Uterus

Rupture Uterus
Rare event Incidence 0.3/1000 deliveries Prompt diagnosis Prompt treatment Delayed diagnosis Increased maternal mortality

Action Plan
When to suspect?
Beware of fetal distress in association with risk factor for uterine rupture

Action Plan -- Maintenance of Airway

Assess Maintain patency Oxygen 15 l/mt via tight fitting mask Attach pulse oximeter Call anaesthetist Consider tracheal intubation

Action Plan -- Maintenance of Breathing

Assess
Ventilate Protect airway

Action Plan -- Maintenance of Circulation

Assess pulse and BP CPR if necessary Put on ECG and automatic BP monitor Treat periarrest arrythmias Secure IV access using two large bore cannulae Send blood for FBC, cross match 6 units and clotting screen Replace intravascular volume as necessary

Action Plan
Call senior obstetrician Obtain consent for laparotomy and hysterectomy Baby alive, cervix fully dilated consider instrumental delivery Perform urgent laparotomy under GA Prophylactic antibiotics

Type of operation is dictated by the size and site of rupture, the degree of haemorrhage and patients future fertility wishes Document in details, incident, assessment, treatment and management plan with date, time and signature

When to suspect ?
Suspect beware of fetal distress in association with risk factor for uterine rupture Sign
Commonest prolonged FHR deceleration (70%) Pain and bleeding, unreliable (7.6% & 3.4%) Cessation of uterine actions with CTG evidence of fetal distress

Risk Factors
Previous CS esp if subjected to oxytocics Previous uterine trauma / surgery Oxytocic usage in multiparous patients Mullerian tract anomalies Forceps deliveries esp Kiellands Multipara with previous FTND and significant larger baby or malposition in present pregnancy when allowed a prolonged second stage

Site of Rupture
Dehiscence of lower uterine segment in cases of previous LSCS Rupture may extend anteriorly towards back of bladder, laterally towards uterine arteries or into broad ligament plexus of veins PPH Posterior rupture is associated usually with uterine malformations. Also seen with post CS, following obstructed labor and rotational forceps deliveries

Surgical Procedure
Sustained haemorrhage indication for hysterectomy Subtotal simpler and quicker besides less risk for damage to bladder and ureter

 RUPTURE UTERUS

Bandls Ring
Also known as Retraction Ring

Seen in Obstructed labor

Pathological Retraction Ring

Gradual increase in intensity, duration and frequency of uterine contractions Phase of relaxation decreases Ultimately tonic contraction sets in Retraction continues Lower segment thinned and stretched Formation of circular groove between active upper and distended lower segment Pronounced retraction decreased flow at placental site fetal distress

Progress of labor
Labor ceases in response to obstruction because of uterine exhaustion In multigravida retraction continues with progressive thinning and dilatation of lower segment and progressive elevation of Bandls ring closer to umbilicus rupture of lower segment

Clinical Features
Pain discomfort because of prolonged labor Maternal exhaustion Keto acidosis Upper segment hard and tender Lower segment distended and tender Ring appreciated running obliquely between umbilicus and symphysis pubis rises with time

Taut and tender round ligaments Absent FHS usual Dry vagina, offensive discharge Cervix fully dilated Cause of obstruction apparent

Management
Condition preventable Supportive treatmentIV fluids Treatment of keto acidosis Sedation Antibiotics

Definitive Relieve obstruction by safe procedure after excluding uterine rupture