Maternal and neonatal outcomes after uterine rupture in labor

OBJECTIVE: There is significant controversy about the risks related to atte mpted vaginal birth after cesarean and the implications for informed consen t of the patient. Recent data suggest that women who deliver in hospitals w ith high attempted vaginal birth after cesarean rates are more likely to ex perience successful vaginal birth after cesarean, as well as uterine ruptur es. We conducted a study to evaluate maternal and neonatal morbidity and mo rtality after uterine rupture at a tertiary care center. STUDY DESIGN: We performed a retrospective chart review of cases of uterine rupture from 1976 to 1998. All women who had a history of uterine rupture were identified with International Classification of Diseases, Ninth Revisi on, identifiers with hospital discharge data cross-referenced with a separa te obstetric database. We abstracted demographic information, fetal heart r ate patterns, maternal pain and bleeding patterns, umbilical cord gas value s, and Apgar scores from the medical record. Outcome variables were uterine rupture events and major and minor maternal and neonatal complications. RESULTS: During the study period there were 38,027 deliveries. The attempte d vaginal birth after cesarean rate was 61.3%, of which 65.3% were successf ul. We identified 21 cases of uterine rupture or scar dehiscence. Seventeen women had prior cesarean deliveries (10 with primary low transverse cesare an delivery, 3 with unknown scars, 1 with classic cesarean delivery, 2 with two prior cesarean deliveries, and 1 with four prior cesarean deliveries). Of the 4 women who had no history of previous uterine surgery, one had a b icornuate uterus whereas the others had no factors increasing the risk for uterine rupture. We confirmed uterine rupture and scar dehiscence in 19 wom en. Specific details were not available for 2 patients. Uterine rupture or scar dehiscence was clinically suspected in 16 women with 3 cases identifie d at delivery or after delivery. Sixteen women had symptoms of increased ab dominal pain, vaginal bleeding, or altered hemodynamic status. There were 2 patients who required hysterectomies and 3 women who received blood transf usions; there were no maternal deaths related to uterine rupture. The fetal heart rate pattern in 13 cases showed bradycardia and repetitive variable or late decelerations. Thirteen neonates had umbilical artery pH >7.0. Two cases of fetal or neonatal death occurred, one in a 23-week-old fetus whose mother had presented to an outlying hospital and the second in a 25-week-o ld fetus with Potter's syndrome. All live-born infants were without evidenc e of neurologic abnormalities at the time of discharge. CONCLUSION: Our data confirm the relatively small risk of uterine rupture d uring vaginal birth after cesarean that has been demonstrated in previous s tudies. In an institution that has in-house obstetric, anesthesia, and surg ical staff in which close monitoring of fetal and maternal well-being is av ailable, uterine rupture does not result in major maternal morbidity and mo rtality or in neonatal mortality.