A couple of weeks ago I had this invitation to a big center whose surgeon apparently had gone on a short vacation. The case was a simple and straight-forward case of a lady who REQUESTED for a caesarian section after being in labour for more than twenty-four hours. This was not a common place thing in our environment where some still regard surgical delivery of babies as a taboo. Some even when the indication is very obvious still wants to seek the consult of their spiritual guardian before giving final consent for surgery. So to hear of a patient asking for a caesarian section without being prodded to do so is a rarity in our environment.
You can imagine that on arrival the surgeon was informed that the anesthetist was not around and the ambulance driver had just been informed to pick him. He didn’t even know he was on call that evening! So, he had used the opportunity to visit his younger brother whose wife had a baby. He eventually showed up after two and half hours. The patient was wheeled in and it was time for the theatre nursing staff to vent their disgruntlement. Questions about viral screening for immunodeficiency, hepatitis B and C viruses were asked together with other equerries. At a point the patient was even asked to go back to the labour ward that the theatre was not ready to receive her! And the lady was in severe pains.
By the time we got through all these distractions and delays, the patient was still wheeled to the operating table. On the fundal end of the abdomen was a curious bulge. She had not been previously diagnosed as having uterine fibroid. Paramount on our mind was to get the baby out and the mother in good condition. The first surprise was the amount of blood we saw in the peritoneal cavity. We knew that there was something seriously wrong. Secondly, we had some challenge trying to extract the baby. Eventually we were able to deliver him.
Out of curiosity we decide to bring out the entire uterus through the wound for examination before suturing the opening through which the baby was delivered. Then we saw the dent on the fundus of the uterus. It had ruptured. The challenge we had trying to get the baby out was as a result of the baby’s leg protruding through the dent and the uterine muscles clasping on it like a tourniquet during contraction; in effect making it a little difficult for the baby to be extracted. We closed the uterine wound and sutured the ruptured site.
For a recap, the rupture of a pregnant uterus simply put results from poor management of labour. In our environment the commonest cause of uterine rupture is the dehiscence of scar from previous surgical intervention. One often gets the history of previous caesarian and the insisting that she wants to try a vaginal delivery. It is very common in this environment to see a patient who abandons a hospital where she had a successful caesarian to another where they do not do C/S. This most of the time leads to catastrophic consequences.
It is common knowledge that what can easily cause the uterine muscles to get torn is when there is a situation of Oxygen lack known as ischaemia. This can easily occur when the uterus is subjected to a state of sustained contraction frequently especially when stimulated by uterotonic medication in the process of induction or augmentation. Lately the usage of prostaglandins for the induction of labour is becoming very popular among care givers. The major drawback is that once administer edit cannot be retrieved if the uterus is endangered by hyper or over stimulation. Oxytocin which is also produced endogenously and has a positive feedback mechanism is preferred because it can easily be discontinued.
When there is obstruction during labour and not detected early due to inexperience. If this labour is augmented, there is a danger of rupture with foetal and maternal demise. Other risk factors that may lead to uterine muscle being torn include multiple pregnancy and previous surgery involving the uterus like the removal of fibroid tumor known as myomectomy.
When the uterus ruptures during labour the following signs can be evident. A severe pain associated with a give can be experienced by the patient who can recollect precisely when it happened. This can be followed by drop in blood pressure and rapid pulse which are signs of impending shock. The patient may start complaining of chest pains. This usually referred pains resulting from the irritation of the Diaphragm by the blood from the bleeding ruptured site. Then comes the ominous signs like the quiscense of the uterus. It just stops contracting and the movement and the heartbeat of the foetus may no longer be felt.
Basically, there two types of uterine rupture caregivers commonly encounter. The first is when the surgeon enters the abdomen, he finds that the peritoneum, the first covering of the visceral abdominal contents even though bloodied is still intact. The second variant is where the peritoneal layer is torn together with the uterus. In most cases in this situation, the foetus would be found lying freely in the abdominal cavity with the intestines and other visceral organs. But this time the baby is already dead from exsanguination.
At this stage apart from the dangers of hypovolemic shock, infection may be another potentially lethal challenge depending on the environment. A ruptured uterus is a desperate obstetric surgical emergency any day. When detected early it is quite possible and, in most cases, to salvage the baby and the mother with minimal complication. The surgery involves the removal of the foetus, dead or alive, and the repair of the uterus. In some very bad cases, this may lead to the removal of the uterus; a surgical procedure known as hysterectomy.
One of the dreaded long-term complications of the catastrophic condition is the necrosis or death of the cells of the anterior pituitary gland which produce trophic sex hormones, thyroid stimulating and adrenocorticotropic hormones. This usually results from shortage of blood supply to the brain during bleeding. An issue that is usually addressed with urgency during the management of uterine rupture. If this happens the patient develops Simmonds’s disease or Sheehan’s syndrome. This jeopardizes the patient’s future reproductive life.
Rupture of the uterus should not be allowed to happen. When situations leading to its occurrence are investigated the blame ultimately is left at somebody’s door step, the care giver. Good antenatal care and being proactive in labour should be the guiding principle.