Uterine Rupture in Pregnancy

Updated: Mar 25, 2016

Author: Gerard G Nahum, MD, FACOG, FACS; Chief Editor: Christine Isaacs, MD more...
https://reference.medscape.com/article/275854-
overview#a8

Overview
Uterine rupture in pregnancy is a rare and often catastrophic complication
with a high incidence of fetal and maternal morbidity. Numerous factors are
known to increase the risk of uterine rupture, but even in high-risk
subgroups, the overall incidence of uterine rupture is low. From 1976-2012,
25 peer-reviewed publications described the incidence of uterine rupture,
and these reported 2,084 cases among 2,951,297 pregnant women,
yielding an overall uterine rupture rate of 1 in 1,146 pregnancies (0.07%).
The initial signs and symptoms of uterine rupture are typically nonspecific,
which makes the diagnosis difficult and sometimes delays definitive
therapy. From the time of diagnosis to delivery, generally only 10-37
minutes are available before clinically significant fetal morbidity becomes
inevitable. Fetal morbidity occurs as a result of catastrophic hemorrhage,
fetal anoxia, or both.
The premonitory signs and symptoms of uterine rupture are inconsistent,
and the short time for instituting definitive therapeutic action makes uterine
rupture in pregnancy a much feared event for medical practitioners.
Definition
Uterine rupture during pregnancy is a rare event and frequently results in
life-threatening maternal and fetal compromise. It can either occur in
women with (1) a native, unscarred uterus or (2) a uterus with a surgical
scar from previous surgery.
Uterine rupture occurs when a full-thickness disruption of the uterine wall
that also involves the overlying visceral peritoneum (uterine serosa) is
present. By definition, it is associated with the following:
Clinically significant uterine bleeding
Fetal distress
Protrusion or expulsion of the fetus and/or placenta into the abdominal
cavity
Need for prompt cesarean delivery
Uterine repair or hysterectomy
In contrast to frank uterine rupture, uterine scar dehiscence involves the
disruption and separation of a preexisting uterine scar. Uterine scar
dehiscence is a more common event than uterine rupture and seldom
results in major maternal or fetal complications.
Importantly, when the defect in the uterine wall is limited to a scar
dehiscence, it does not disrupt the overlying visceral peritoneum and it
does not result in clinically significant bleeding from the edges of the pre-
existing uterine scar. In addition, in cases of uterine dehiscence (as
opposed to uterine rupture), the fetus, placenta, and umbilical cord remain
contained within the uterine cavity. If cesarean delivery is needed, it is for
other obstetrical indications and not for fetal distress attributable to the
uterine disruption.
Although a uterine scar is a well-known risk factor for uterine rupture (most
of which arise from prior cesarean delivery), the majority of events involving
the disruption of uterine scars result in uterine scar dehiscence rather than
uterine rupture. These two entities must be clearly distinguished, as the
options for clinical management and the resulting clinical outcomes differ
significantly.
Sources of information and study selection
The peer-reviewed literature was searched using the PubMed, Medline,
and Cochrane databases for all relevant articles published in the English
language. The search terms were uterine rupture, pregnancy and prior
cesarean section, vaginal birth after cesarean, VBAC, trial of labor (TOL),
trial of labor after cesarean (TOLAC), uterine scar dehiscence, and
pregnancy and myomectomy. Standard reference tracing was also used.
Articles published from 1976 through May, 2012 that described the
incidence of uterine rupture and that included sufficient information
regarding the authors' definitions of uterine rupture and of uterine scar
dehiscence were incorporated for review. All studies were observational or
reviews. A total of 133 published articles were included for data extraction
and analysis.
Incidence and risk factors
Meta-analysis of pooled data from 25 studies in the peer-reviewed medical
literature published from 1976-2012 indicated an overall incidence of
pregnancy-related uterine rupture of 1 per 1,416 pregnancies (0.07%).
When the studies were limited to a subset of 8 that provided data about the
spontaneous rupture of unscarred uteri in developed countries, the rate
was 1 per 8,434 pregnancies (0.012%).
Congenital uterine anomalies, multiparity, previous uterine myomectomy,
the number and type of previous cesarean deliveries, fetal macrosomia,
labor induction, uterine instrumentation, and uterine trauma all increase the
risk of uterine rupture, whereas previous successful vaginal delivery and a
prolonged interpregnancy interval after a previous cesarean delivery may
confer relative protection. In contrast to the availability of models to predict
the success of a vaginal delivery after a TOLAC, accurate models to predict
the person-specific risk of uterine rupture in individual cases are not
available.
The major patient characteristics for determining the risk of uterine rupture
are noted below.
Uterine status is either native (unscarred) or scarred. Scarred status may
include previous cesarean delivery, including the following:
Single low transverse (further subcategorized by 1-layer or 2-layer
hysterectomy closure)
Single low vertical
Classic vertical
Multiple previous cesarean deliveries
Scarred status may also include previous myomectomy (transabdominal or
laparoscopic).
Uterine configuration may be normal or may involve a congenital uterine
anomaly.
Pregnancy considerations include the following:
Grand multiparity
Maternal age
Placentation (accreta, percreta, increta, previa, abruption)
Cornual (or angular) pregnancy
Uterine overdistension (multiple gestation, polyhydramnios)
Dystocia (fetal macrosomia, contracted pelvis)
Gestation longer than 40 weeks
Trophoblastic invasion of the myometrium ( hydatidiform mole,
choriocarcinoma)
Previous pregnancy and delivery history may include the following:
Previous successful vaginal delivery
No previous vaginal delivery
Interdelivery interval
Labor status is determined as follows:
Not in labor
Spontaneous labor
Induced labor - with oxytocin, with prostaglandins
Augmentation of labor with oxytocin
Duration of labor
Obstructed labor
Obstetric management considerations include the following:
Instrumentation ( forceps use)
Intrauterine manipulation (external cephalic version, internal podalic
version, breech extraction, shoulder dystocia, manual extraction of
placenta)
Fundal pressure
Uterine trauma includes the following:
Direct uterine trauma (eg, motor vehicle accident, fall)
Violence (eg, gunshot wound, blunt blow to abdomen)
Rupture of the Unscarred Uterus
The normal, unscarred uterus is least susceptible to rupture. Grand
multiparity, neglected labor, malpresentation, breech extraction, and uterine
instrumentation are all predisposing factors for uterine rupture. A 10-year
Irish study by Gardeil et al showed that the overall rate of unscarred uterine
rupture during pregnancy was 1 per 30,764 deliveries (0.0033%). No cases
of uterine rupture occurred among 21,998 primigravidas, and only 2
(0.0051%) occurred among 39,529 multigravidas with no uterine scar. [1]
A meta-analysis of 8 large, modern (1975-2009) studies from industrialized
countries revealed 174 uterine ruptures among 1,467,534 deliveries. This
finding suggests that the modern rate of unscarred uterine rupture during
pregnancy is 0.012% (1 in 8,434). This rate of spontaneous uterine rupture
has not changed appreciably over the last 50 years, and most of these
events occur at term and during labor. An 8-fold increased incidence of
uterine rupture of 0.11% (1 in 920) has been noted in developing countries,
with this increased incidence of uterine rupture having been attributed to a
higher-than-average incidence of neglected and obstructed labor due to
inadequate access to medical care.
When the risk of uterine rupture for women with different types of risk
factors is assessed, these baseline rates of pregnancy-related uterine
rupture in women with native, unscarred uteri, specifically, the rates of
0.012% (1 in 8,434) for women living in industrialized countries and 0.11%
(1 in 920) for women living in developing countries, represent observational
benchmarks that should be referenced for all comparisons.
Effect of maternal parity
Many authors have considered multiparity a risk factor for uterine rupture.
Golan et al noted that, in 19 of 61 cases (31%), uterine rupture occurred in
women with a parity of more than 5. [2] Schrinsky and Benson found that 7
of 22 women (32%) who had unscarred uterine rupture had a parity of
greater than 4. [3] In a study by Mokgokong and Marivate, the mean parity
for women who had pregnancy-related uterine rupture was 4. [4] Despite the
apparent increase in the risk of uterine rupture associated with high parity,
Gardeil et al found only 2 women with uterine rupture among 39,529
multigravidas who had no previous uterine scar (0.005%). [1]
Rupture of the unscarred uterus before labor versus during labor
Schrinsky and Benson reported 22 cases of uterine rupture in gravidas with
unscarred uteri. Nineteen occurred during labor (86%), and 3 occurred
before labor (14%). This percentage was markedly different from that of
gravidas with a previous uterine scar, for whom the timing of uterine rupture
between labor and the antepartum period was nearly evenly distributed. [3]
Oxytocin augmentation and induction of labor in the unscarred uterus
The use of oxytocin for labor augmentation versus labor induction is often
quite different. The two patient populations widely vary in their key
attributes, as well as in the oxytocin doses that are typically given, which
systematically varies between the two groups. Despite this, many
investigations concerning the use of oxytocin and the risk of uterine rupture
have failed to make this distinction.
In 1976, Mokgokong and Marivate reported 260 uterine ruptures among
182,807 deliveries that involved unscarred uteri, and 32 of the 260 (12%)
were associated with oxytocin use. [4] Rahman et al similarly found that
oxytocin was administered in 9 of 65 cases (14%) that involved unscarred
uterine rupture. [5] Golan et al noted that, among 126,713 deliveries,
oxytocin was used in 26 of 61 cases (43%) that involved unscarred uterine
rupture. [2] However, Plauche et al attributed only 1 of 23 unscarred uterine
ruptures (4%) to the use of oxytocin. [6]
Based on this type of limited information, the increased risk of uterine
rupture attributable to the use of oxytocin in gravidas with unscarred uteri is
uncertain. However, women who have had a cesarean delivery appear to
have an increased risk of uterine rupture associated with the use of
oxytocin, both when it is used for labor augmentation and labor induction
(see Table 1).
Congenital uterine anomalies
In a review article, Nahum reported that congenital uterine anomalies affect
approximately 1 in 200 women. [7] In such cases, the walls of the abnormal
uteri tend to become abnormally thin as pregnancies advance, and the
thickness can be inconsistent over different aspects of the myometrium
(uterine musculature). [8, 9, 10,11]
Ravasia et al reported an 8% incidence of uterine rupture (2 of 25) in
women with congenitally malformed uteri compared with 0.61% (11 of
1,788) in those with normal uteri (P =.013) who were attempting
VBAC. [12] Both cases of uterine rupture in the women with uterine
anomalies involved labor induction with prostaglandin E2.
In contrast, a study of 165 patients with Mllerian duct anomalies who
underwent spontaneous labor after 1 prior cesarean delivery reported no
cases of uterine rupture. [13] Of note, in this study 36% (60 of 165) had only
a minor uterine anomaly (arcuate or septate uterus), and 64% (105 of 165)
had a major uterine anomaly (unicornuate, didelphys, or bicornuate uterus).
Moreover, only 6% (10 of 165) of patients with Mllerian duct anomalies
underwent induction of labor.
For pregnancies that implant in a rudimentary horn of a uterus, a
particularly high risk of uterine rupture is associated with the induction of
labor ( 81%; 387 of 475 cases). [14] Importantly, 80% of ruptures involving
these types of rudimentary horn pregnancies occurred before the third
trimester, with 67% occurring during the second trimester.
The decision for induction of labor in women with a congenitally anomalous
uterus, especially in cases of a previous cesarean delivery, must be
carefully considered, given the higher incidence of uterine rupture reported
in this patient population. Although the uterine rupture rate for unscarred
anomalous uteri during pregnancy is increased relative to that for normal
uteri, the precise increase in risk associated with the different types of
uterine malformations remains uncertain.
Previous Uterine Myomectomy and Uterine Rupture
Previous myomectomy by means of laparotomy
Nearly all uterine ruptures that involve uteri with myomectomy scars have
occurred during the third trimester of pregnancy or during labor. Only 1
case of a spontaneous uterine rupture has been reported before 20 weeks
of gestation. [15]Brown et al reported that among 120 term infants delivered
after previous transabdominal myomectomy, no uterine ruptures occurred,
and 80% of the infants were delivered vaginally. [16] In contrast, Garnet
identified 3 uterine ruptures among 83 women (4%) who had scars from a
previous myomectomy and who underwent elective cesarean delivery
because of previous myomectomy. [17]
Such reports do not often delineate the factors that were deemed important
for assessing the risk of subsequent uterine rupture (eg, number, size, and
locations of leiomyomata; number and locations of uterine incisions; entry
of the uterine cavity; type of closure technique). Further studies to
investigate these issues are needed.
Previous laparoscopic myomectomy
Dubuisson et al reported 100 patients who underwent laparoscopic
myomectomy and found 3 uterine ruptures during subsequent
pregnancies. [18] Only 1 rupture occurred at the site of the previous
myomectomy scar, resulting in the conclusion that the risk of pregnancy-
related uterine rupture attributable to laparoscopic myomectomy is 1%
(95% CI, 0-5.5%). However, the rarity of spontaneous uterine rupture
raises the issue of whether the 2 uterine ruptures at sites that were not
coincident with previous myomectomy scars were attributable to the
previous myomectomies. If so, a markedly higher 3% uterine rupture rate is
associated with previous laparoscopic myomectomy.
Different authors reported no pregnancy-related uterine ruptures in 4
studies of 320 pregnancies in women who previously underwent
laparoscopic myomectomy.[19, 20, 21, 22] However, in all 4 studies, the number
of patients who were allowed to labor was low, and a high percentage of
deliveries were by scheduled cesarean delivery (80%, 79%, 75%, and
65%, respectively).
In a prospective study from Japan, there were no uterine ruptures among
59 patients with a successful vaginal delivery after a prior laparoscopic
myomectomy.[23] In a multicenter study in Italy with 386 patients who
achieved pregnancy after laparoscopic myomectomy, there was 1 recorded
spontaneous uterine rupture at 33 weeks' gestation (rupture rate
0.26%). [24]
Uterine rupture has been reported to occur as late as 8 years after
laparoscopic myomectomy. [25] This finding suggests that additional
investigations with long-term follow-up are needed.
Rupture of the Scarred Uterus Due to Previous
Cesarean Delivery
The effect of previous cesarean delivery on the risk of uterine rupture has
been studied extensively. In a meta-analysis, Mozurkewich and Hutton
used pooled data from 11 studies and showed that the uterine rupture rate
for women undergoing a TOLAC was 0.39% compared with 0.16% for
patients undergoing elective repeat cesarean delivery (odds ratio [OR],
2.10; 95% CI, 1.45-3.05). After restricting the meta-analysis to 5
prospective cohort trials, similar results were found (OR, 2.06; 95% CI,
1.40-3.04). [26]
Hibbard et al examined the risk of uterine rupture in 1,324 women who
underwent a TOLAC. They reported a significant difference in the risk of
uterine rupture between women who achieved successful vaginal birth
compared with women in whom attempted vaginal delivery failed (0.22% vs
1.9%; OR, 8.9; 95% CI, 1.9-42). [27] The effect of previous cesarean delivery
on the rate of subsequent pregnancy-related uterine rupture can be further
examined according to additional subcategories, which are summarized in
Table 1.
Relevant to this issue of vaginal birth after cesarean section (VBAC) is that
the overall rate in the United States increased from 3.4% in 1980 to a peak
of 28% in 1996. Commensurate with this 8-fold increase in the VBAC rate,
reports of maternal and perinatal morbidity also increased, in particular with
reference to uterine rupture. By 2007, the VBAC rate in the United States
had fallen nationally to 8.5%. Not surprisingly, the cesarean delivery rate
also reached an all-time high of 32% in 2007. In its most recent guidelines
pertaining to VBAC in August 2010, the American Congress of
Obstetricians and Gynecologists (ACOG) adopted the recommendation not
to restrict women's access to VBAC. [28] This occurred after the National
Institutes of Health (NIH) Consensus Development Conference Panel
reviewed the totality of the evidence concerning maternal and neonatal
outcomes relating to VBAC in March 2010. [29]
Previous classic cesarean delivery
Classic cesarean delivery via vertical midline uterine incision is infrequently
performed in the modern era and currently account for 0.5% of all births in
the United States. [30] In a meta-analysis, Rosen et al reported an 11.5%
absolute risk of uterine rupture (3 of 26 cases) in women with classic
vertical cesarean scars who underwent an unplanned TOLAC. [31] For
women who underwent repeat cesarean section, Chauhan et al reported
that the uterine rupture rate for 157 women with prior classical uterine
cesarean scars was 0.64% (95% CI, 0.1-3.5%). All patients in that study
underwent repeat cesarean delivery, but a high rate of preterm labor
resulted in 49% of the patients being in labor at the time of their cesarean
delivery. [30]
Landon et al reported a 1.9% absolute uterine rupture rate (2 of 105 cases)
in women with a previous classic, inverted T, or J incision who either
presented in advanced labor or refused repeat cesarean delivery. [32] These
rates of frank uterine rupture in women with classic cesarean deliveries are
in contrast to the higher rates of 4-9% that the American College of
Obstetricians and Gynecologists (ACOG) had historically reported for
women with these types of uterine scars. However, Chauhan et al
observed a 9% rate of asymptomatic uterine scar dehiscence (95% CI, 5-
15%). [30] This result suggests that disruptions of uterine scars might have
been misclassified as true ruptures instead of dehiscences in previous
studies; this error may explain the bulk of the discrepancy.
Previous low vertical cesarean delivery
A meta-analysis of pooled data from 5 studies demonstrated a 1.1%
absolute risk (12 of 1,112 cases) of symptomatic uterine rupture in women
undergoing a TOLAC with a low vertical cesarean
scar. [32, 33, 34, 35, 36] Compared to women with low transverse cesarean
scars, these data suggest no significantly increased risk of uterine rupture
or adverse maternal and perinatal outcomes.
Interpretation of these studies is hampered by inconsistencies in how high
the lower uterine segment could be cut before it was considered a classic
incision. Even when the lower uterine segment is already well developed as
a result of active labor, a low vertical incision of adequate length is often
impossible to permit fetal delivery. Naef et al arbitrarily defined a 2-cm
extension into the upper segment as a classic extension. For 322
pregnancies that occurred after a low vertical cesarean delivery, the overall
rate of uterine rupture was 0.62%. This rate could be further divided as
1.15% for 174 women who underwent a TOLAC compared with no ruptures
among 148 women who underwent elective repeat cesarean delivery. [33]
Unknown uterine scar
In many instances, the type of incision used for a prior cesarean delivery
cannot be confirmed due to unavailability of the operative report. Under
these circumstances, the assessment of uterine rupture risk may
sometimes be guided by the obstetric history to infer the most probable
type of uterine scar. For example, a patient with a history of a preterm
cesarean delivery at 28 weeks gestation has a much higher likelihood of
having had a vertical uterine incision than a patient who underwent a
cesarean section for an indication of arrest of fetal descent at term.
Diagnosis
Because of the short time available to diagnose uterine rupture before the onset of
irreversible physiologic damage to the fetus, time-consuming diagnostic methods
and sophisticated imaging modalities have only limited use. Therefore, uterine
rupture is most appropriately diagnosed on the basis of standard signs and
symptoms (see Table 2).
Despite this limitation, various diagnostic techniques have been used to attempt to
assess the individual risk of uterine rupture in selected patients. Amniography,
radiopelvimetry, and pelvic examination have all proven unsuitable for predicting the
risk of uterine rupture in women who desire a TOLAC. In addition, imaging modalities
such as CT and MRI have not been clinically useful in diagnosing acute uterine
rupture because of the time constraints involved in establishing the diagnosis. Given
this limitation, MRI is thought to be superior to CT for evaluating the status of a
uterine incision because of its increased soft tissue contrast. All studies of these
methods are limited by their retrospective design and their lack of surgical
confirmation of true uterine dehiscence.
Several reports have suggested that transabdominal, transvaginal, or
sonohysterographic ultrasonography may be useful for detecting uterine-scar defects
after cesarean delivery. Rozenberg et al prospectively examined 642 women and
found that the risk of uterine rupture after previous cesarean delivery was directly
related to the thickness of the lower uterine segment, as measured during
transabdominal ultrasonography at 36-38 weeks of gestation. The risk of uterine
rupture increased significantly when the uterine wall was thinner than 3.5 mm. Using
a 3.5 mm cutoff, the authors had a sensitivity of 88%, specificity of 73.2%, positive
predictive value of 11.8%, and a negative predictive value of 99.3% in predicting
subsequent uterine rupture. [95]
In a study of 722 women, Gotoh et al reported that a uterine wall thinner than 2 mm,
as determined with ultrasonography performed within 1 week of delivery, significantly
increased the risk of uterine rupture. Positive and negative predictive values were
73.9% and 100%, respectively. [96]
Management of the Ruptured Uterus
Treatment
The most critical aspects of treatment in the case of uterine rupture are
establishing a timely diagnosis and minimizing the time from the onset of
signs and symptoms until the start of definitive surgical therapy. Once a
diagnosis of uterine rupture is established, the immediate stabilization of
the mother and the delivery of the fetus are imperative.
As a rule, the time available for successful intervention after frank uterine
rupture and before the onset of major fetal morbidity is only 10-37
minutes. [44, 88, 91, 97, 101]Therefore, once the diagnosis of uterine rupture is
considered, all available resources must quickly and effectively be
mobilized to successfully institute a timely surgical treatment that results in
favorable outcomes for both the newborn and the mother.
After the fetus is successfully delivered, the type of surgical treatment for
the mother should depend on the following factors:
Type of uterine rupture
Extent of uterine rupture
Degree of hemorrhage
General condition of the mother
Mother's desire for future childbearing
Uterine bleeding is typically most profuse when the uterine tear is
longitudinal rather than transverse. Conservative surgical management
involving uterine repair should be reserved for women who have the
following findings:
Desire for future childbearing
Low transverse uterine rupture
No extension of the tear to the broad ligament, cervix, or paracolpos
Easily controllable uterine hemorrhage
Good general condition
No clinical or laboratory evidence of an evolving coagulopathy
Hysterectomy should be considered the treatment of choice when
intractable uterine bleeding occurs or when the uterine rupture sites are
multiple, longitudinal, or low lying.
Because of the short time available for successful intervention, the
following 2 premises should always be kept firmly in mind: (1) Maintain a
suitably high level of suspicion regarding a potential diagnosis of uterine
rupture, especially in high-risk patients, and (2) when in doubt, act quickly
and definitively.
Prevention
The absolute risk of uterine rupture in pregnancy is low, but it is highly
variable depending on the patient subgroup (see Table 1). Women with
normal, intact uteri are at the lowest risk for uterine rupture (1 in 8,434
pregnancies [0.012%]).
The most direct prevention strategy for minimizing the risk of pregnancy-
related uterine rupture is to minimize the number of patients who are at
highest risk. The salient variable that must be defined in this regard is the
threshold for what is considered a tolerable risk. Although this choice is
ultimately arbitrary, it should reflect the prevailing risk tolerance of patients,
physicians, and of society as a whole. If this threshold is chosen as 1 in
200 women (0.5%) (see Table 1), the categories of patients that exceed
this critical value are those with the following:
Multiple previous cesarean deliveries
Previous classic midline cesarean delivery
Previous low vertical cesarean delivery
Previous low transverse cesarean delivery with a single-layer
hysterotomy closure
Previous cesarean delivery with an interdelivery interval of less than 2
years
Previous low transverse cesarean delivery with a congenitally
abnormal uterus
Previous cesarean delivery without a previous history of a successful
vaginal birth
Previous cesarean delivery with either labor induction or augmentation
Previous cesarean delivery in a woman carrying a macrosomic fetus
weighing >4000 g
Previous uterine myomectomy accomplished by means of laparoscopy
or laparotomy
Conclusion
Uterine rupture is a rare but often catastrophic obstetric complication with
an overall incidence of approximately 1 in 1,536 pregnancies (0.07%). In
modern industrialized countries, the uterine rupture rate during pregnancy
for a woman with a normal, unscarred uterus is 1 in 8,434 pregnancies
(0.012%).
The vast majority of uterine ruptures occur in women who have uterine
scars, most of which are the result of previous cesarean deliveries. A single
cesarean scar increases the overall rupture rate to 0.5%, with the rate for
women with 2 or more cesarean scars increasing to 2%. Other subgroups
of women who are at increased risk for uterine rupture are those who have
a previous single-layer hysterotomy closure, a short interpregnancy interval
after a previous cesarean delivery, a congenital uterine anomaly, a
macrosomic fetus, prostaglandin exposure, and a failed previous trial of a
vaginal delivery.
Surgical intervention after uterine rupture in less than 10-37 minutes is
essential to minimize the risk of permanent perinatal injury to the fetus.
However, delivery within this time cannot always prevent severe hypoxia
and metabolic acidosis in the fetus or serious neonatal consequences.
The most consistent early indicator of uterine rupture is the onset of a
prolonged, persistent, and profound fetal bradycardia. Other signs and
symptoms of uterine rupture, such as abdominal pain, abnormal progress
in labor, and vaginal bleeding, are less consistent and less valuable than
bradycardia in establishing the appropriate diagnosis.
The general guideline that labor-and-delivery suites should be able to start
cesarean delivery within 20-30 minutes of a diagnosis of fetal distress is of
minimal utility with respect to uterine rupture. In the case of fetal or
placental extrusion through the uterine wall, irreversible fetal damage can
be expected before that time; therefore, such a recommendation is of
limited value in preventing major fetal and neonatal complications.
However, action within this time may aid in preventing maternal
exsanguination and maternal death, as long as proper supportive and
resuscitation methods are available before definitive surgical intervention
can be successfully initiated.