18.18 Rupture of the uterus

Uteri can rupture before or during delivery, but in only about two-thirds of cases do you make the diagnosis before you deliver the baby. In the rest you make it afterwards, usually after some difficult obstetric manoeuvre, such as a retained placenta (18.14), or a destructive operation (18.7), or after a trial of scar (18.14). Here we are mostly concerned with rupture of the uterus before delivery, as a complication of obstructed labour.

Figure 18.21: SUSPICIOUS EVIDENCE. If a postpartum patient has a mass contiguous with the uterus (A), which does not disappear on catheterizing the bladder (B), but persists (C), it is probably a haematoma of her broad ligament due to rupture of her uterus. If a previous Caesarean section has left scar D, suspect strongly that it was classical. Scar E, might be either. F, is almost certainly a lower segment scar. After Nash and Drouin with the kind permission of the Editor of Tropical Doctor

Section 18.4 describes the management of obstructed labour. If a mother, particularly a multip, arrives too late, or you do not recognize that she has obstructed, her uterus is likely to rupture. This is a great obstetric disaster. If primary care is really bad in your district, 50% of the mothers referred to you may need an operative delivery, and of these 5% may have ruptured their uteri.

The usual story, which is described in more detail in Sections 18.1 and 18.3, is that a mother is admitted from her village in obstructed labour, having waited a long time in a rural health centre for transport to hospital. She is often sufficiently clear-headed to be able to tell you that she had strong frequent pains which stopped suddenly.

When her uterus ruptures there may be a direct communication between her uterine cavity and her peritoneal cavity (complete rupture), or her peritoneum or her bladder may separate the baby from her peritoneal cavity (incomplete rupture, less common). If her membranes ruptured some time before delivery, the contents of her uterus will be infected, and her uterine muscle bruised and in poor condition for repair.

Never try to deliver a mother with a ruptured uterus vaginally. Aim to: (1) Resuscitate her and operate soon. (2) Remove the baby and the placenta. (3) Control bleeding. (4) Repair or remove her uterus on the indications given below. Unless the rupture is extensive, and her tissues are particularly bruised and oedematous, repairing her uterus is likely to be easier than removing it, because the distortion of her anatomy makes hysterectomy difficult. But even repair is not easy, because the edges of the tear are ragged and not easy to bring together. Hysterectomy takes longer than repair, and causes more bleeding. A subtotal hysterectomy, which leaves her cervix and perhaps part of her lower segment, is easier than a total one; it causes less bleeding, and there is less danger to her ureters. If you have to remove her uterus, try to leave one ovary. The secret of success is to exert continued traction on her uterus (20.12), and to identify important structures and landmarks before you start to cut or suture them.

Speed is critical. Most time is lost getting her to the theatre, and in getting it ready, so make sure that it always is ready. If you are not familiar with the anatomy, study Figures 20-16 and 20-17!