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Rupture Uterus
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Rupture Uterus
Rare event
Incidence 0.3/1000 deliveries
Prompt diagnosis
Prompt treatment
Delayed diagnosis
Increasedmaternal mortality
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Action Plan
When to suspect?
Beware of fetal distress in association
with risk factor for uterine rupture
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Action Plan -- Maintenance of
AirwayAssess
Maintain patency
Oxygen 15 l/mt via tight fitting mask
Attach pulse oximeter
Call anaesthetistConsider tracheal intubation
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Action Plan -- Maintenance of
BreathingAssess
Ventilate
Protect airway
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Action Plan -- Maintenance of
CirculationAssess pulse and BP
CPR if necessary
Put on ECG and automatic BP monitorTreat periarrest arrythmias
Secure IV access using two large borecannulae
Send blood for FBC, cross match 6 units andclotting screen
Replace intravascular volume as necessary
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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
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Type of operation is dictated by the size
and s ite of rup tu re, the degree of
haemorrhage and patients futurefer t i li ty w ishes
Document in detai ls, incident,
assessment, treatment andmanagement plan with date, time and
signature
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When to suspect ?
Suspectbeware of fetal d istressin
association with r isk factor fo r uter ine
ruptureSign
Commonest prolonged FHR deceleration(70%)
Pain and bleeding, unreliable (7.6% & 3.4%)
Cessat ion of uter ine act ionswith CTG evidence
of fetal distress
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Risk Factors
Previous CSesp if subjected to oxytocics
Previous uterine t rauma / su rgery
Oxytoc icusage in mult iparouspatientsMuller ian tract anomalies
Forceps deliveries esp Kiellands
Multipara with previous FTND and significantlarger baby or malposition in presentpregnancy when allowed a prolongedsecond stage
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Site of Rupture
Dehiscence of lower uterine segment in
cases of previous LSCS
Rupture may extend anteriorly towards backof bladder, laterally towards uterine arteries
or into broad ligament plexus of veinsPPH
Posterior rupture is associated usually with
uterine malformations. Also seen with post
CS, following obstructed labor and rotational
forceps deliveries
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Surgical Procedure
Sustained haemorrhage indication for
hysterectomy
Subtotal simpler and quicker besidesless risk for damage to bladder and
ureter
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RUPTURE UTERUS
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Bandls RingAlso known as Retraction Ring
Seen in Obstructed labor
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Pathological Retraction Ring
Gradual increase in intensity, duration andfrequency 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 segmentPronounced retractiondecreased flow at
placental sitefetal distress
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Progress of labor
Labor ceases in response to obstruction
because of uterine exhaustion
In multigravida retraction continues withprogressive thinning and dilatation of lower
segment and progressive elevation of
Bandls ring closer to umbilicusruptureof lower segment
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Clinical Features
Pain discomfort because of prolonged labor
Maternal exhaustion
Keto acidosisUpper segment hard and tender
Lower segment distended and tender
Ring appreciated running obliquely betweenumbilicus and symphysis pubisriseswith time
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Taut and tender round ligaments
Absent FHS usual
Dry vagina, offensive discharge
Cervix fully dilated
Cause of obstruction apparent
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Management
Condition preventable
Supportive treatment-
IV fluidsTreatment of keto acidosis
Sedation
Antibiotics
DefinitiveRelieve obstruction by safeprocedure after excluding uterine rupture