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.

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!

Fig. 18-19 RUPTURE OF THE UTERUS. A, a ruptured uterus may look like this. B, a tear in the anterior wall with a vertical extension at one end. C, a tear involving the bladder. D, a tear in the lateral wall opening into the broad ligament. E, a transverse tear in the posterior wall. F, a tear which almost detaches the uterus. G, the tear from a classical Caesarean section.

RUPTURE OF THE UTERUS DIAGNOSIS. Be aware of impending rupture when labour is obstructed, especially in a multip, and try to prevent it happening by intervening immediately.

Impending rupture: (1) Bandl's ring between the upper and lower segments rises. (2) The lower segment becomes stretched and painful to touch, even between contractions, which increase in strength and duration. (3) The patient becomes anxious and restless, with a rapid pulse and irregular respiration.

Actual rupture: (1) Her uterine contractions stop suddenly and are replaced by no pain (common), or less pain, or severe continuous pain (uncommon). (2) She is shocked and pale before delivery, or she becomes shocked afterwards, and does not repond to transfusion immediately (especially if the placenta is retained). (3) She may bleed from her vagina, sometimes quite severely, sometimes not at all. If the presenting part is jammed in her pelvis no blood can escape from her vagina. In this situation, see if she has a haemoperitoneum by aspirating both her iliac fossae. (4) Her uterus is tender to palpation (it may feel soft, or be permanently tense). Later, her entire abdomen may be tender. (5) The baby may be abnormally difficult to feel (common) or abnormally easy (uncommon). Sometimes, the shape of her uterus changes, and you may be able to feel him outside it (usually his limbs are close under her abdominal wall, a certain sign of rupture). If he is in her broad ligament, you will be unable to feel him. (6) His head may previously have been low in her pelvis, but has now risen higher and may now be no longer palpable vaginally. (7) Bloodstained urine. (8) The absence of a fetal heartbeat, unless the tear is a small one, and he is still in her uterus. (9) The appearance of the placenta at her vulva before he is delivered (uncommon). (10) The prolapse of loops of gut into her vagina (uncommon).

Shock or severe vaginal bleeding may dominate the picture. Her blood pressure is low and her pulse is fast. She is usually lucid, and may even be talkative, which may delude you into thinking she is less ill than she really is.

If she is in obstructed labour, and you are still not sure if she has ruptured her uterus or not, resuscitate her, prepare for laparotomy, give her a general anaesthetic, intubate her, and examine her vaginally in the lithotomy position. The presenting part may have disengaged, so that your hand passes through the rupture into her abdominal cavity, allowing you to feel the inner surface of her abdominal wall. You may find that the presenting part is unexpectedly easy to dislodge, and the attempt to do this is followed by a gush of blood. If it is not easy to dislodge, try to pass a catheter by pushing it up a little vaginally. If this fails, stop for fear of damaging her urethra. Pass your fingers anterior to the presenting part, into her uterus and feel for a rupture. If there is one, you will feel the inner surface of her abdominal wall. If there is no rupture, deliver her vaginally (18.7).

CAUTION ! (1) Dramatic symptoms of rupture are uncommon. (2) If you are about to attempt a vaginal delivery, but have any suspicion that her uterus may have ruptured, take her to the theatre. Be prepared to give her a general anaesthetic and to do a laparotomy, if necessary.

DIFFERENTIAL DIAGNOSIS. Rupture of the uterus is not the only cause of collapse during an obstructed labour, it can also be due to septic shock (53.4), electrolyte imbalance, or dehydration (A 15.3) or:

Suggesting abruption with a massive concealed haemorrhage but no rupture[md]a tense, tender uterus. The important sign of abruption is a closed or nearly closed cervix[md]it is always open in obstructed labour.

CAUTION ! Beware of diagnosing abruption in a patient with a previous Caesarean section. Rupture is much more likely, even if she has not been in labour long.

RESUSCITATION. Do this vigorously in the theatre or the labour ward. Internal jugular or subclavian puncture (A 15.2) is better than a cut down. Give her at least a litre of 0.9% saline before anaesthesia starts, and 100 mmol of sodium bicarbonate to correct her acidosis. Operate as soon as you can, don't wait too long; adequate resuscitation is impossible if she is still bleeding inside. Continue to resuscitate her while you operate. Put up two drips, one for saline or Ringer's lactate given fast, and the other for blood (53.2, A 16.7).

If she is sufficiently conscious to understand, explain that you would like to tie her tubes. If she is not fit enough to understand, her relatives will. It is seldom necessary to tie tubes without permission. As a general rule, no woman who has had a ruptured uterus should ever become pregnant again (see below). The only exception is an extraperitoneal (partial) rupture through a lower segment scar.

CAUTION ! Don't try to deliver the baby before she is resuscitated, because this will remove his tamponading effect, increase shock, and perhaps extend the tear.

PERIOPERATIVE ANTIBIOTICS. Start these (2.9). Avoid gentamicin before anaesthesia (A 14.3).

EQUIPMENT. A ''Caesar set' and some large curved clamps or artery forceps. You will need a scrubbed second assistant, besides the scrub nurse, the anaesthetist, and a ''runner'.

ANAESTHESIA. Pass a nasogastric tube, aspirate her stomach, and instil 30 ml of magnesium trisilicate. (1) If you give her a general anaesthetic, intubate her under cricoid pressure (A 16.7). (2) If her condition is poor, local infiltration anaesthesia will be safest (A 6.9). (3) A ketamine drip (8.3). Avoid subarachnoid or epidural anaesthesia, because she is already hypotensive.

EXPLORATION [s7]FOR RUPTURE OF THE UTERUS Clip or shave her, wash her abdomen, and pass a catheter. This will prevent you mistakenly opening a high full bladder. Make a low midline or paramedian incision (9.2), and insert a self-retaining retractor.

You will see blood, and a tear in her uterus. Her dead baby (common) and the placenta (sometimes) may be in her peritoneal cavity. If the placenta is still attached to her uterus, he may be alive (rare), even if he is lying free in her peritoneal cavity. If it is detached, he will be dead, wherever he is.

If he is lying free in her peritoneal cavity, the rupture is complete. Remove him.

If he is in her broad ligament, open it. This is most easily done by dividing the round ligament over it.

If he is still in her uterus, as with a posterior rupture, deliver him through a transverse incision in the lower segment, as for Caesarean section.

Suck out blood and liquor. There may be bleeding, or this may have stopped, especially if the tear is transverse across the vessels.

If you have not already given her ergometrine, give it as soon as he is delivered. Lower the head of the table and pack off her gut.

Deliver the empty uterus into the wound and inspect it, especially its posterior wall[md]there may be a second tear. Find the edges of the tear along its whole length. Divide her round ligament if this makes the tear easier to see.

The tear may: (1) Be in the anterior wall of her uterus, often with a vertical extension at one end, making it L[nd]shaped (B, in Fig. 18-19). (2) Extend into her bladder (C). (3) Extend longitudinally, along the lateral wall of her lower segment, from her fundus to her vagina, opening up her broad ligament and involving a uterine artery (D). Tears of this kind are more common on the left. (4) Extend transversely across the posterior wall of her uterus (E, rare). (5) Detach the uterus almost completely (F, rare). (6) Be in the upper segment through the scar of an old classical Caesarean section (G). Often, one of her uterine pedicles is torn across.

Feel for the placenta and detach it from her uterus with your fingers. Use swabs on a holder to remove as much of the membranes as you can.

Control bleeding from her uterus with No. 2 chromic catgut. Or, clamp the edges of the tear with several pairs of Green Armytage forceps. Control bleeding from her broad ligament temporarily with pressure from a pack. If she has an extensive haematoma tracking up from the torn vessels on one side towards her kidney, evacuate it and tie them.

REPAIR OR HYSTERECTOMY? The indications depend on: (1) The nature and extent of the rupture. (2) Your experience.

If you are inexperienced, only do a hysterectomy if repair seems very difficult.

If you have some hysterectomy experience, factors favouring a repair are: (1) A rupture which is not too large. (2) A rupture with clean edges which are easy to see and are not too oedematous. (3) Little or no infection. Factors favouring a hysterectomy are: (1) Extensive or multiple tears. (2) Edges which are very bruised and oedematous and not easy to define, especially some posterior ruptures, or ruptures extending down into her vagina. (3) Gross infection of her uterus.

THE REPAIR [s7]OF A RUPTURED UTERUS Start by defining the position of her uterine pedicles, her ovarian pedicles, and her round ligaments.

If the tear extends into her cervix or lower segment, reflect her bladder as for a lower segment Caesarean section. Avoid her ureter. Ask your assistant to pull her uterus forwards and to the other side. Lift her tube and ovary, so as to make her infundibulopelvic ligament, which carries her ovarian vessels, taut. Put your thumb and index finger on either side of this ligament, and slide them down. Feel for her ureter as a hard round cord near her pelvic brim. From there trace it down to the injured area. See also Fig. 20-16.

Remove all clot. If she bleeds a little, disregard it. If she bleeds much, apply haemostats or transfixion sutures.

CAUTION ! (1) Be sure to keep her bladder well away from the edges of the tear. (2) Don't excise any tissue unless it is obviously dead.

Start at the apex of the tear; if convenient hold it with a stay suture. Suture it as for Caesarean section, using 2 layers of continuous catgut in a large half-circle round-bodied needle (size ''2' or ''3'). You can suture a vertical tear going down to the cervix from below upwards, but sometimes the other way round is easier. Traction on the suture will help to bring the lower end into view. Don't worry if the inner layer has to be placed inside her uterus. Make the second layer an inverting continuous suture. If necessary, use extra sutures to close off the corners, or repair her vagina (usually anteriorly).

If the rupture is lateral and has extended into her broad ligament, open its peritoneal roof, and tie the bleeding vessels. Control any oozing with under-running stitches. Avoid her ureter. With one finger inside her broad ligament and another behind it, feel for her ureter; if necessary, pass a tape under it to keep it out of the way. Start at the apex and work downwards. Exert traction on the running suture to expose the depths of the tear. Stop before you reach the lower edge, so as to leave room for a drain from her broad ligament into her vagina. If there is much oozing, pack her broad ligament with a gauze bandage, bring it out of her vagina, and close the visceral peritoneum over it. Remove the pack 12 hours later.

Fig. 18-20 ANATOMY FOR EMERGENCY HYSTERECTOMY. The patient's uterus seen from behind before hysterectomy. It is tilted to the left and her adnexa (ovary and tube) have been lifted up to show them more clearly. For simplicity the tear is not shown.

1, the body of her uterus. 2, her right Fallopian tube. 3, her ovary. 4, her round ligament. 5, her ovarian vessels running in her infundibulopelvic ligament which is being stretched. 6, her uterine vessels. 7, her rectum. 8, her sacrouterine ligament. 9, the avascular area in her broad ligament. Kindly contributed by Frits Driessen.

HYSTERECTOMY [s7]FOR A RUPTURED UTERUS The following description differs from that in Section 20.12, and is modified for rupture of the uterus. Consult the illustrations in that chapter, and particularly the account of the anatomy of the ureters, vessels, and ligaments. Hysterectomy may be surprisingly easy when the tear is extensive and transverse, and the uterus almost completely detached.

INDICATIONS. (1) Complicated rupture of the uterus (also see above). (2) Postpartum haemorrhage, which is not responding to treatment, and when tying the internal iliac arteries (3.5) has failed to control bleeding.

METHOD. Remove the baby and the placenta and clean away most of the blood and liquor. Insert a self-retaining retractor, and lift her uterus from her abdomen. Maintain traction on it with one hand, or insert a traction suture.

Start by identifying: her uterus and round ligaments, her tubes and ovaries on both sides, her infundopelvic ligaments, the avascular area in each of her broad ligaments, her lower segment, her rectum, and especially her ureters. You will find this difficult, because of the size of her uterus, and the disturbance to her normal anatomy caused by bruising and oedema, both near the tear, and far from it.

Deflect her bladder, and trace her ureters over the whole length of the operative field as described above (20-16). Find where they are in relation to the tear, in the distal part of their course.

You will have difficulty deciding where her uterus ends and her vagina begins. Feel for a small ridge of tissue (the remains of her cervix) on the ''inside'[md]but even this may be absent. If you are still not sure, it will merely mean that you will not know if you have done a total or a subtotal hysterectomy. In view of her present state, this hardly matters.

Find the tear and clamp the obvious bleeding points. Pull her uterus to the left, and divide her right round ligament between clamps about 2 cm from it. This will open the anterior peritoneal leaf of her broad ligament. Enlarge this opening down towards her bladder. Lift her right tube and ovary with one hand, and push a finger of your other hand from behind through the avascular area in her broad ligament.

CAUTION ! Leave her ovary and tube in place on one or both sides.

On the side on which you will remove her ovary, clamp her infundopelvic ligament between two artery forceps and cut it. On the other side, to retain her tube and ovary, clamp and divide her tube and her ovarian ligament near her uterus. If they are very thick and vascular, you may have to clamp and cut them in two steps.

Transfix the pedicles of her round ligaments and infundibulopelvic ligaments with ''2' multifilament or chromic catgut.

Using the clamps that you have already applied, pull her uterus well up in the midline, and cut the peritoneum between her uterus and her bladder. Extend the incision laterally to meet the incisions you have made in the anterior leaves of her broad ligaments.

Push her bladder off her lower segment for 2 or 3 cm with a swab on a holder. Pushing it further down can cause bleeding. If the rupture is anterior, put its edge on the stretch before you separate off her bladder.

Now expose the back of her lower segment by pulling her uterus forwards over her symphysis pubis. Divide the peritoneum over the back of her lower segment at the same level as you did anteriorly. Extend the incisions laterally to join the openings in her broad ligament. Push the lower flap of peritoneum off her lower segment with a swab on a holder; or, if this is difficult, cut it loose with scissors.

On either side of her uterus there will now be a bundle of loose connective tissue containing her uterine vessels. If necessary strip down the peritoneum of her broad ligaments to see them more clearly.

Pull her uterus to the right and clamp her uterine vessels with strong Kocher forceps, just above the level where her bladder is still attached to her lower segment.

CAUTION ! Make sure the points of the forceps are close to her uterus.

Place a second clamp inside the first, and cut her uterine vessels between them. Tie and transfix the pedicle. Use a double transfixion ligature because of its width.

Do the same thing on the other side.

Excise her uterus through its lower segment, just above the level of her cut uterine vessels. Have artery forceps ready to pick up the cut edge of her lower segment, before it disappears in the depth of her pelvis. Clamp any bleeding vessels.

If the tear extends across her lower segment, it will probably serve as the ''line of cutting' to remove her uterus. Examine the edge and remove any very oedematous and bruised tissue, again checking the position of her ureters first.

If there is a downward tear in her cervix, repair this now, after making sure that her bladder and ureters are well out of the way. Alternatively, do a total hysterectomy, and remove her cervix.

Suture the anterior and posterior walls of her lower segment with figure of eight stitches, being sure to include the angles on each side, because these bleed. If there are signs of infection, leave the centre open so that you can insert a drain; otherwise close it.

Her pelvis should now be nearly dry. Tie any remaining bleeders.

If her broad ligaments are oozing, place a drain near them and bring it out through her vagina.

Close her pelvic peritoneum with a continuous suture. Start on the left at the pedicle of her infundopelvic ligament, and suture the anterior edge of her peritoneum to the posterior edge, placing all vascular pedicles under it. Let her remaining ovary and tube hang freely in her pelvis.

CLOSING HER ABDOMEN [s7](after hysterectomy or repair) Always tie her tubes after a repair, unless you have repaired a lower segment Caesarean scar, and she is likely to return for an elective section at the start of her next labour.

If her condition is unstable, close her abdomen without delay. If it is stable search for additional injuries, especially to her bladder.

Clean and wash her peritoneum with at least two litres of warm saline. Instill 1 g of tetracycline in 1000 ml of warm saline (2.9). Close it with No. 0 or 2/0 catgut. Close her abdominal wall as usual. Monitor her haemoglobin. ''Suck and drip' her (9.9, A 15.5). Keep a catheter in her bladder until her condition is satisfactory, and monitor her urine output carefully: it should be at least 1 ml/kg/hour (A 15.5). If she has a postoperative diuresis, usually at 24 to 48 hours, be sure to give her potassium (A 15.5, 9.9).

Watch for anuria (53.3), respiratory complications (9.11), peritonitis (6.2), and peritoneal abscesses (6.3). Remember her nutrition; if there are no signs of peritonitis, start feeding her orally with a high-energy high-protein mixture as soon as her bowel function allows it, a few days after the operation (58.11). If there are no complications this can usually start on the 3rd postoperative day.

DIFFICULTIES [s7]WITH RUPTURE OF THE UTERUS If her BLADDER IS TORN, its wall near the opening is usually stuck to her lower segment, and needs mobilizing before you can repair it. You may find that her bladder is so torn that it lies flat like a handkerchief.

Use Allis' forceps or Babcock clamps to stretch the wall of her bladder and her lower segment. Suck away the blood. Separate her bladder from her lower segment with a ''swab on a stick', or with scissors. Gently dissect it off the lower segment, taking care not to make the tear any bigger. Free the bladder wall round the opening for 1 or 2 cm.

Close the opening in her bladder with two layers of 2/0 continuous catgut. Put the first layer through the full thickness of her bladder wall, but just submucosal if possible. If this is difficult, include the mucosa. Use the second layer to invert the first one. Insert an indwelling catheter and maintain open drainage (an unspigoted catheter) for 10 to 14 days. Unfortunately, complete closure of the bladder is often impossible; its edges are usually thin and necrotic, so that a fistula follows.

If complete CLOSURE OF HER TORN BLADDER IS IMPOSSIBLE, because there is much presure necrosis, or the opening extends far down into her urethra, you may have to close her bladder over a wide[nd]bore suprapubic tube. If she develops a vesico[nd]uterine fistula, repair it later, or refer her to have it repaired.

If you think that you have CAUGHT HER URETER in a suture, unpick it; usually there is no permanent harm. Alternatively, open her bladder and cannulate it. If severe damage is confirmed, the only way to preserve the function of her kidney is to reanastomose it over a splint, or to reimplant it in her bladder. An intravenous injection of methylene blue or indigo carmine may help to show leaks in her ureter (18.10).

If she is ANAEMIC after delivery with a BOGGY PELVIC SWELLING and deviation of her uterus, she probably has a PELVIC HAEMATOMA. This is really a rupture of her uterus which has bled into her broad ligament instead of into her peritoneal cavity. If you see her [lt]24 hours after delivery, do a laparotomy and explore and repair her rupture. If you see her [mt]24 hours after delivery and she is stable, treat her non- operatively in the hope that her haematoma will resolve.