2017; Shmudi, 2017). Perhaps related, almost a fourth of VBAC deliveries were completed with either forceps or vacuum (Inbar, 2017). he merican Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) have concluded that epidural analgesia while pushing. The rupture apparently stimulated a reflex push, after which uterine tone may safely be used during TOLAC. diminished and fetal bradycardia worsened.
FIGURE 31-6 Maternal-Fetal Medicine Units Network: rates of some complications with increasing number of repeat cesarean deliveries. (Data from Silver RM, Landon MB, Rouse OJ, et al: Maternal morbidity associated with mUltiple repeat cesarean deliveries. Obstet Gynecol 207:1o226, 2006.)
In some women, the clinical appearance of uterine rupture mirrors that of placental abruption. In most, however, there is remarkably little appreciable pain or tenderness. Also, because most women in labor are treated for discomfort with either narcotics or epidural analgesia, pain and tenderness may not be readily apparent. The condition usually becomes evident because of fetal distress and occasionally because of maternal hypovolemia from concealed hemorrhage.
If the fetal presenting part has already entered the pelvis with labor, loss of station may be detected by pelvic examination. If the fetus is partly or totally extruded from the uterine rupture site, abdominal palpation or vaginal examination may be help ful to identiY the presenting part, which will have moved away from the pelvic inlet. A irm contracted uterus may at times be felt alongside the fetus. Sonography may be helpful.
With rupture and expulsion of the fetus into the peritoneal cavity, the chances for intact fetal survival are dismal, and reported mortality rates range from 50 to 75 percent. Fetal condition depends on the degree to which placental implantation remains intact, although this can change within minutes. With rupture, the only chance of fetal survival is aforded by immediate delivery-most often by laparotomy-otherwise, hypoxia is inevitable. If rupture is followed by total placental separation, then very few neurologically intact fetuses will be salvaged.
Thus, even in the best of circumstances, some etal outcomes wil be impaire. he Utah experiences are instructive here (Holmgren, 2012). Of the 35 laboring patients with uterine rupture, the decision-to-delivery time was < 18 minutes in 17, and none of these infants had an adverse neurological outcome. Of the 18 born > 18 minutes from decision time, the three infants with long-term neurological impairments were delivered at 31, 40, and 42 minutes. There were no deaths, thus severe neonatal neurological morbidity developed in 8 percent of this group of 35 women with uterine rupture.
In a study using the Swedish Birth Registry, Kaczmarczyk and coworkers (2007) found that the risk of neonatal death following uterine rupture was 5 percent. In the Network study cited earlier, seven of the 114 uterine ruptures associated with TOAC-6 percent-were complicated by development of neonatal HIE (Spong, 2007).
Maternal deaths from uterine rupture are uncommon. Of 2.5 million women who gave birth in Canada between 1991 and 2001, there were 1898 cases of uterine rupture, and four of these-0.2 percent-resulted in maternal death (Wen, 2005). In other regions of the world, however, maternal mortality rates are much higher. From rural India, the maternal mortality rate associated with uterine rupture was 30 percent (Chatterjee, 2007).