European Journal of Obstetrics & Gynecology

ELSEVIER and Reproductive Biology 56 (I 994) IO7- 110

Uterine rupture in pregnancy reviewed

Francois Gardeil *, Sean Daly, Michael J. Turner

Coombe WornenS Hospital, Dublin 8, Ireland

Accepted 17 June 1994

Abstract

Uterine rupture is associated with maternal and fetal mortality and morbidity. In developed countries there have been many
recent advances in the management of labour. This study, therefore, reviewed this Hospitals experience of uterine rupture in the
decade lY82 to 1991. Excluding cases of asymptomatic scar dehiscence, there were 15 cases of uterine rupture in 65,488 deliveries,
giving an overall incidence of 1 in 4,366. There was no case of rupture in 2 1,998 primigravidas. Of the 15 cases, only two occurred
in 39,529 multigravidas without a previous uterine scar (1 in 19,765), and 13 cases occurred in the 3,961 multigravidas with a pre-
vious caesarean section scar (1 in 304). Twelve of the 13 ruptures after caesarean section occurred in the delivery immediately after
the section. There were no maternal deaths but five (33%) patients required a hysterectomy. Three of the five perinatal deaths were
attributable to the rupture. Ten of the 15 patients had labour induced, and a total of 13 patients received an oxytocic agent. Of
the 15 cases, 8 were diagnosed during labour and 7 postpartum. Compared with earlier reports from Dublin, the incidence of uterine
rupture was low due to a decrease in the number of ruptures associated with trauma or obstetric manipulation. The main associated
feature was previous caesarean section. This review highlights the risk of uterine rupture when an oxytocic agent is administered
to a multigravid patient with a previous caesarean section scar.

Keywords: Uterine rupture; Previous caesarean section; Oxytocic agents

1. Introduction ture in countries where population demographics and

In obstetrics, the end of the twentieth century brings
with it continuing technical developments, especially in
fetal surveillance. Clinical practice is changing, leading
to increasing caesarean section rates and a higher inci-
dence of epidural anaesthesia [I]. It is against this
background that we decided to review our recent experi-
ence of uterine rupture in pregnancy. The decrease in the
birth rate and in the incidence of multiparity has chang-
ed our obstetric population; these demographic changes
may create a situation where many clinical problems
become rare and others, for example labour following
previous caesarean section, become more commonplace.
The incidence of uterine rupture has been reported as
varying between 1 in 585 deliveries [2] and 1 in 6673 de-
liveries [3]. Many recent reviews report on uterine rup-
~-
* Corresponding author.
social services are not what they are in most developed
countries [4,5]. The conclusions and recommendations
from such reports, therefore, may not be applicable to
developed countries. The aim of this study was to review
uterine rupture in a modern obstetric unit in a developed
country in which the caesarean section rate has increas-
ed from 7.8% to 11.3% over the last seven years and the
incidence of epidural anaesthesia is now 45.8% [l].
2. Patients and methods
All deliveries of infants weighing 500 g or more be-
tween 1982 and 1991 inclusive were reviewed. Cases of
asymptomatic scar dehiscence which were incidental fin-
dings at the time of repeat caesarean section were ex-
cluded, as in other series [6-81. A complete rupture was
defined as a rupture involving the full thickness of the
uterine wall and the overlying pelvic peritoneum 191.

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108 F. Gardeil et al. /Eur. J. Obster. Gynecol. Reprod. Biol. 56 (1994) 107-110
Rupture of the uterus was classified into two groups:
rupture of the previously scarred uterus and rupture of
the unscarred uterus [4]. The cases were identified by
reviewing the theatre records for the 10 year period
1982-1991. The clinical notes of each case were avail-
able, which permitted analysis of risk factors which may
have contributed to the rupture. The maternal and fetal
outcomes were also recorded.
3. Results
Over the 10 years there were 65,488 deliveries in the
hospital. There were 15 cases of uterine rupture, giving
an overall incidence of 0.023% or 1 in 4,366 deliveries.
Parity of the patients ranged from 1 to 6. There was no
case of uterine rupture in 2 1,998 primigravidas. The in-
cidence among multigravidas was 0.034% or 1 in 2,900
deliveries. Of the 15 cases of uterine rupture, 12 oc-
curred in patients who were allowed to labour following
lower segment caesarean section. Notably. in 11 cases
the rupture occurred in the pregnancy immediately
following the caesarean section. The incidence of rup-
ture in this group was 0.42% or 1 in 236 deliveries (Table
1). One case of rupture occurred in a patient who had
had three previous caesarean sections. She presented at
the hospital in labour at 29 weeks gestation. Uterine
rupture was suspected before she went for emergency re-
peat abdominal delivery and was confirmed at laparoto-
my. There were only two cases of uterine rupture in
patients with an unscarred uterus. Both were associated
with high parity (Para 4 and Para 6).
Eleven patients received oxytocin, eight for induction
and three for augmentation of labour. In one of those,
oxytocin was started after a presumptive diagnosis of
abruptio placentae had been made. The commonest in-
dication for oxytocin induction was post-date pregnancy
(5 cases). Two inductions were for prelabour spontane-
ous membrane rupture at 37 and 38 weeks gestation,
respectively. One patient had labour induced for
suspected intrauterine growth retardation. There were
two prostaglandin inductions: one for a post-date preg-
nancy where the fetus was anencephalic and one for an
Table 1
Incidence of uterine rupture in the different groups of patients
Cases Incidence
rupture
Primigravidas (n = 21,998) 0 0
Multigravidas (n = 43,490)
- No previous scar (n = 39,529) 2 I in 19,765
- Previous scar(s). Planned repeat
caesarean section (n = 1,129) 1 1 in 1,129
- Previous scar. Allowed to labour
(n = 2,832) 12 1 in 236
Table 2
Uterine rupture in patients allowed to labour following lower segment
caesarean section (n = 12): intrapartum risk factors
Oxytocin to induce labour 7
Oxytocin to augment labour 3
Prostaglandin induction 1
Epidural anaesthesia 7
Operative vaginal delivery 3
Note: Combination oxytocin induction + epidural in 4 cases.
Combination oxytocin augmentation + epidural + operative vaginal
delivery in 3 patients.
intrauterine death diagnosed at 28 weeks gestation. Epi-
dural anaesthesia was provided on request for eight
women; seven of these had a previous caesarean section
and among this group four had labour induced using
oxytocin; a further three required oxytocin augmenta-
tion of labour (Table 2).
The diagnosis of uterine rupture was made during
labour in eight patients and after delivery in seven
patients. The intrapartum diagnosis of uterine rupture
was always associated with a fetal heart-rate abnormali-
ty. Abdominal pain occurred in all women who did not
have an epidural block but in none of the women who
had epidural analgesia. Clinical examination revealed
abnormal uterine configuration in three cases and vagi-
nal bleeding was reported in one case.
Seven cases of rupture were diagnosed following de-
livery. Of these, four were associated with an operative
vaginal delivery; three forceps deliveries and one ven-
touse. In three other cases a manual removal of the pla-
centa was required and the uterine rupture was
diagnosed during the procedure. The postpartum diag-
nosis of rupture was associated with abdominal pain,
tenderness and significant vaginal bleeding.
Following diagnosis of rupture, a laparotomy was
performed in every patient. The rupture was found to be
complete in 11 cases (73.3%) and incomplete in the re-
maining four cases (26.7%). In three cases of complete
rupture there was extrusion of the fetus and placenta
into the maternal abdomen. One of these infants was
live-born and responded well to resuscitation.
Ten ruptures occurred in the lower segment and three
of these were associated with bladder rupture. It is in-
teresting to note that in two patients who had a previous
of lower segment caesarean section scar the rupture had
occurred lateral to an intact scar and not alongside it.
Uterine repair was possible in 10 cases (66%); in two of
these it was combined with a bladder repair. Hysterecto-
my was performed in five patients (33%); one of these
also required a bladder repair. All the cases which re-
quired hysterectomy were complete ruptures and re-
quired blood transfusion of 6 units or more. In the 10
patients who did not require hysterectomy two subse-
quently delivered four babies by elective caesarean sec-
 F. Gurdeil et al. /Eur. J Ohster. Gynecol. Reprod. Biol. 56 (1994)
tion (one had one baby and the other had three babies).
There was no case of recurrent rupture.
There was no maternal death associated with uterine
rupture. There were live perinatal deaths, giving a peri-
natal mortality rate of 33%. There were three intrapar-
turn deaths, one neonatal death and one antepartum
death. Of the intrapartum deaths, one was an anence-
phalic fetus. Uterine rupture was associated with 0.65%
of all the cases of perinatal death in this hospital in the
10 years 1982-1991.
4. Discussion
Even in developed countries, uterine rupture is associ-
ated with an increase in maternal morbidity and peri-
natal mortality. The incidence of uterine rupture in our
series was low, with an overall incidence of one in 4,366
deliverie,s. In a previous series of 54,000 deliveries
reported from Dublin the incidence was one in 1,200
1101.
There was no case of uterine rupture in nearly 22,000
primigravidas. Our series supports the view that
primigravidas are almost immune to rupture of the
uterus [l 11. In our series rupture of an unscarred uterus
accounted for only two cases: this is a low incidence
compared to previous reports [ 121. A series of 143 cases
of rupture reported from all three Dublin hospitals be-
tween the years 1954 and 1964 showed that 100 occurred
in patients without a previous caesarean section [ 131.
Thus, the remarkable reduction in the incidence of
uterine rupture in Dublin is due to a decrease in the
number of ruptures in women with unscarred uteri.
The majority (80%) of cases of rupture occurred in
women allowed to labour following lower segment
caesarean section. The dictum once a caesarean always
a caesarean, arising from the potential for rupture of
any previous scar, has never been the practice in this
hospital. where patients who have had one previous
lower segment caesarean section are allowed to labour
in the absence of a recurrent indication for caesarean
section or a new indication that precludes vaginal deliv-
ery. Oxytocin is used in these patients for either induc-
tion or augmentation of labour whenever necessary but
only after a full clinical assessment by a senior obstetri-
cian. During the 10 years 1982-1991, 83.2% of the pa-
tients who laboured after caesarean section achieved a
vaginal (delivery. In this group of patients an incidence
of rupture of 1 in 236 deliveries (0.42%) may seem to be
a reasonable price to be paid for the avoidance of a great
number of unnecessary repeat elective abdominal deliv-
eries. Nevertheless the obstetrician must always be
aware of the clinical circumstances in which uterine rup-
ture may occur.
The use of oxytocin in women who have had a
caesarean section is controversial. It has been claimed
that it was contraindicated [6] but more recent reports
107-110 109
have failed to show an increased incidence of uterine
rupture associated with the use of oxytocin [14,15].
However, in the 12 patients in this series whose uterus
ruptured during a trial of labour, 11 had received an ox-
ytocic agent (Table 2). Eight of these twelve women had
had labour induced (66.6%). This rate of induction can
be compared with the overall induction rate for women
allowed to labour following caesarean section during the
study period, which was 19%.
The use of epidural analgesia in patients with a pre-
vious scar is also controversial. Some authors consider
it safe [16] but it has been stated that epidural analgesia
is contraindicated because it masks the pain caused by
uterine rupture and delays the diagnosis [ 171. In our
series abdominal pain occurred in all women who were
without epidural analgesia and in none of the women
who had received an epidural block. Previous research
in this hospital showed that the combined use of oxyto-
tin and epidural analgesia significantly increases the risk
of uterine rupture [14]. This association was found in 7
patients in our series. In general, patients who have la-
bour induced are more likely to request epidural
analgesia.
It is interesting to note that the induction rate among
women who had had a previous caesarean section was
actually higher than the rate in the general hospital pop-
ulation during the 10 year period 1982- 199 1. If such in-
tervention was reduced, the vaginal delivery rate might
be improved and the risk of uterine rupture might
decrease. The indication for induction of labour in any
woman who has a previous caesarean section should be
carefully considered. Early dating ultrasonic examina-
tions and careful fetal assessment after 40 weeks gesta-
tion should decrease the need to induce labour
post-date. It has been shown that in cases of pre-labour
membrane rupture after one previous caesarean section,
awaiting the spontaneous onset of labour can safely
achieve a high rate of vaginal delivery and avoid the
need to induce labour with oxytocin [ 181.
The need for early diagnosis and prompt surgical in-
tervention in such a potentially catastrophic obstetric
emergency has been previously highlighted [19]. The
diagnosis of uterine rupture depends on a high degree of
suspicion. Continuous fetal monitoring is advisable in
patients labouring after caesarean section. Fetal heart-
rate abnormalities were a constant finding in our series,
as in others [8,14,20].
Surgical management of uterine rupture depends on
the type and site of the rupture, the extent of the bleed-
ing and the wishes of the woman with regard to future
fertility. Repair of the uterus was considered possible in
66% of our patients. Sterilization was not performed at
the time of repair and two patients subsequently
delivered four babies by elective caesarean section. Re-
pair of the uterus without sterilization was first recom-
mended in 1968 [21]. In a recent article from Dublin, 18
110 F. Gardeil et al. /Eur. J. Obster. Gynecol. Reprod. Biol. 56 (1994) 107-110

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