3. Rupture of Uterus - Lecture notes 1 PDF

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RUPTURE OF THE UTERUS Definition:-

Is the tear of the wall of the uterus which may be complete or incomplete.

a). Complete rupture:-

Is a tear in the wall of the uterus with or without expulsion of the fetus into the peritoneal cavity.

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The tear involves the endometrium, myometrium and perimetrium.

b). Incompl Incomplete ete rupture -

Is the tear of the endometrium and myometriuml but not perimetrium or one of the two layers.

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The perimetrium remains intact.

Dehiscence of an existi existing ng uterine sear:-

This is the rupture of an existing ( c/s or hysterectomy) uterine scar but the fetal membranes remain intact.

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The fetus is retained within the uterus and not expelled into the peritoneal cavity.

Causes of uterine ruptur rupture e

i. Weak uteri uterine ne scar:-

Is usually a previous caesarean section or hysterectomy scar; or other uterine surgery.

 Predisposing F Factors:actors: The uterine sear may rupture due to: i. Impaired healing of the sear – weak scar ii. Inter pregnancy interval of less than 6/12 - weak scar iii. Obstructed labour – hypertonic uterine action iv. Incorrect use of oxytocin – hypertonic uterine action v. Trauma during manipulation – excessive stretching of scar tissue vi. Over distension of the uterus due to multifetal pregnancy or polyhydramnios 1

ii. Obstructed labour: labour:- Uterine rupture is caused by excessive thinking of the lower uterine segment  Predisposing F Factors actors are:i. Multiparity ii. Over stimulation of the uterus –i.e. use of oxytocics in the presence of CPD iii. Cervical dystocia.

iii. Incorrect use of o oxytocis:xytocis: This refers to excessive use, over dosage or injudicious use of oxytocics.  Predisposing F Factors actors are:i.

Disproportion –i.e. giving oxytoci c in a case of CPD

ii.

Obstructed labour –i.e. administering oxytocin in a case of obstructed labour

iii.

Multiparity –i.e. a multiparous uterus is more sensitive to oxytocics, hence, hypertonic counteractions

 Use of prostaglandins to induce labour in the presence of an existing scar.

during g manipulation:iv iv.. Rupture durin  Uterine rupture may occur during internal podalic or cephalic version procedures or when attempting to correct shoulder presentation.  The chances of rupture are greater in the presence of i. Uterine sear ii. Obstructed labour

laceration ation ation::v. Extension of cervical lacer  Is the extension of a severe cervical laceration upwards into the lower uterine segment.  This occurs a result of:i.

Forceps delivery prior to full cx dilatation

ii.

The mother pushing the baby out through partially dilated cervix

vi. High parity vii. Neglected labour where there is history of previous C/S

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viii. Perforation of a non-pregnant uterus resulting in the rupture of uterus in a subsequent pregnant; and rupture occur I the upper segment

UTERINE RUPTURE DURING THE ANTENA ANTENAT TAL PERIOD:

Rupture of uterus antenatally is a rare event



It involves rupture of a C/S scar-usually classical sear and occurs in the last four weeks of pregnancy.

Clinical presentation 

Is insidious (secretly) is onset and is sometimes referred to as silent rupture



The woman complains of intermittent right side pain for several days



The pain is not always severe is due to peritoneal invitation caused y bleeding from the uterine sear



There is abdominal tenderness which increases and the woman eventually become shocked



Intrauterine fetal death commonly occur

Diagnosis:

Should be suspected when a woman with C/S scar presents with the above symptoms



Rupture (silent rupture) may only be confirmed as laparatomy

Management 

The following may be done: o Hysterectomy o repair of the sear if the woman wishes to have more children



If the ruptured sear repair is done, advice the woman not become pregnant for at least a year to allow the sear to heal completely

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Future pregnancies must be closely monitored and the woman admitted to hospital at 36/40 for rest and observation

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The woman is delivered in future pregnancies by elective caesarean section at 38/52 3

INTERP INTERPAR AR ART TAL (DURING LLABOUR) ABOUR) RUPTURE OF A C/S SE SEAR:AR:This is the rupture of a previous c/s sear during labour This is the rupture of a previous c/s sear during labour.

Signs & symptoms 

Severe constant abdominal pain worsening during contractions



There is suprapubic abdominal tenderness



There may be vomiting



There is rap id pulse due to blood loss



Shock occurs and deepens progressively



There may be some fresh P.V blood loss which may be mistaken for show



The progress of labour stops and the cervix fouls to dilate in first stage and the fetus fails to descend in the second stage of labour

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There is profound fetal tarchycardia or bradycardia or on fetal least sounds following its death

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Uterine contractions ceased. This occasionally occur at ahigh opf a strong contraction and the woman rapidly becomes shocked. Fetus may be palpated as a separate mass in the abdomen from the uterus

Diagnosis:From the clinical features above

Management:

Summon the doctor –C/S



Immediately prepare fro laperatomy is hysterectomy and/or repair of the uterus



Start her immediately on Hartman’s solution to alternate with dextrose solution

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Take blood for Hb, GXM and transfusion may be commenced according to medical instruction

Uterine rupture following obstructed labour

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Early detection of signs of obstructed labour with prompt management will prevent uterine rupture due to obstructed labour

Signs of Impend Impending ing Uterine Rupture (W (Warning arning Signs) 

Rapid pulse



Tonic uterine contractions



Bandl’s retraction ling seen abdominally

Signs of actual rupture 

Severe constant abdominal pain



P.V bleeding (not always present)



Severe fetal dislikes. Fetal death rapidly follows if c/s is not urgently done

Lapar Laparatomy atomy 

Irregular uterine outline :-If the rupture is complete the fetus may be expelled into the pelvic cavity and is palpated as a separate mass with fetal parts easily palpable under the abdominal wall



There is maternal shock (slow/rapid onset) the rate of outset of shock depends on  Extent of uterine rupture  The amount of blood loss Management



Immediately summon the doctor



Taking blood specimen for  Hb  G XM and prepare blood for urgent transfusion (administer according to doctor’s instruction).



If fetal heart beat is still present monitor continuously record/report



Immediately prepare and escort for c/s or is the rupture is extensive then total or sub-total hysterectomy is done on if the tear is less extensive then repair is done if the woman still wishes to have more children. 5

Admit Assess

Management in labour 1. Admission 2. Summon doctor 3. Assessment –TPR B’P/FHR/contractions/bladder/physical SD…state etc 4. J.V fluids 5. Urinary bladder 6. Gastric secretions ranitidine 7. Specific cause MX 

Uterine intertia (hyptonia)



CPD

8. Pain relief 9. Ambulation 10. Diet 11. Bowel care 12. Hygiene 13. Social/spiritual/psychological

PROL PROLONGED ONGED LLABOUR ABOUR Definition:Labour is prolonged when it exceeds 24 hours from the time of onset.

Active MY MY::When labour is actively managed, it is said to be prolonged when it exceeds 12 hours from the time of establishment (Active phrase)

The first stage:- (0-3cm –CX) 6

Prolonged latent phase:

Latent phase is prolonged if it takes over 20 hrs in primigravidae



Latent phase is prolonged if it takes over 14hours in multrigravidae

Primary dysfuncti dysfunctional onal labour:This is situation I which the progress in the active phase of labour is slow and the cervix dilates at less than 1cm/hr.

Secondary arrest:This is where cervical dilatation is arrested in the active phase of labour following a normal progress in the latent phase.

Causes off prol prolonged onged labour (first stage) 1. Abdomina powers:Inefficient uterine action causing slow or no cervical dilatation i.e. the hypotonic or inco-ordinate uterine action

2. Abdominal passage:The pelvis is either contracted or there is/are pelvic tumour (s). The fetus cannot pass through. There may be a rigid perineum.

3. Abnormality of the passenger:Theses include: 

Large fetus, malposition on malpresentation which inhibit the progress of labour

4. Psychological causes:An abnormally tense apprehensive woman tends to have prolonged, especially, primigravida

Clinical features- 1st stage 

The mother appears anxious and tired



The mother has delhydration –dry lips etc 7



The mother usually have ketosisi especially is she has not fed or been given i.v-inf. e.g dextrose

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Slow painful dilatation of the cervix or not at all

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Membranes tends to rupture early due to poor application of the presenting pat to the cervix

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There may be blood stained urine

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There may be varriying degress of ca……succedaneum

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There is excessive molding of the head in cephalic presentations

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The mother may develop PIH or edampsia in the …. Of labour

NB Prolonged labour is often associated with CPD

Management -1st stage 

Admit to hospital and assess/examine



Immediately sumon the doctor as you do the following:-



Perform meticulous assessment of the maternal condition noting any abnormalities and report e.g.: Exhaustion  Dehydration  Kelosis  Severity of pain of uterine contractions



Take maternal vital signs –TP & BP



Fever may be due to infection –antibiotics

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Rapid pulse may be due to ketosis –Dexrose

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Advice the woman to adopt any position she feels most comfortable but surprise position to avoid aortocaval conclusion which amy lead to supine hypotension

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Perform an abdominal examination noting the  L…. e.g. transverse/oblique longitudinal  Presentation e.g. shoulder /cephalic/breech  Position e.g. opp/anterior  Engagement e.g high head 8

 Contractions and report accordingly 

Perform a vaginal examination initially and then 4 hourly noting the following  Whether valka is oedemations or not  State of the vagina  Warm & moist  Tight & rigid  Hot & dry  Degree of dilatation & efforcement  Cervical oedema or any abnormality  Whether membranes are intact or not & R/o cord mesentation or prolapse and report



If the membranes had long ruptued Broad spectum antibiotics are administered to prevent maternal uterine infection and longenital/intapastal pneumonia in the body.



Monitor uterine action 1/2hrly/ continuously and if the mother is in severe pain  Back rib is done  Encourage change of position  Analgesia eg epidurial block/ Entonox is given if there exist no  Containdicatin. 

Epidural pain

analgesia is preferred as

it ensures rest/sleep/ and adequate

relief

 If she is dehydrated

stired an intravenous infusion of Hastmans

solution 1 litre should be given first then alternate with dextiose. Maintain a record of flicid input &  Energy  Hydration & balance

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output

 Encourage

the

women to pass urine frequently as regularly

and every urine specimen tested for volume glucose, proteins and acetone. Abnomalities noted must be coverted immediately. If she is unable to pass urine spontaneously then pass a catheter to empty the bladder.

 Oral sanitidine 150 mg 6hrly is given to reduce gastric secretions

 The specific cause of

prolonged labours must be managed

appropriately e.o CPD - C/S, or hypotonic uterine ation ,mx appropriately  e.g hypotonic uterus-give low dose syntocinous by i.v infusion in N/saline to augment labour

NB Case must be taken to avoid

hyponataemia when administering syntocinou dexicose as it may compromise maternate & fetal wellbeing.

Auseultate fatal heart sounds 1/2hrly or continuously and report fetal bradyeardia or tachoconusdia. If there is fetal distress do the folloeing  Immediately report  Give oxygen by face marsk  Give 5-10% d extrose by i.v-in  Ensure the mother adopt Lt. lateral position

NB

Severe fetal distress calls for termination of labour by C/s

 Hygiene/keep her dry  Heducate  Midwife mother without labour  Keep the cardex 10

 Keep all the record upto date

2nd stage: Causes of prolonged 2nd stage:

1 Hypotonic uterine action: Usually secondary uterine

hypotonia

Mx: Administer i.v-inf. syntocinou to stimulate adequate contiactions

2 Ineffetive

maternal effort

May be caused by 

Fear



Exhaustions



Lack of sensation inhibiting the woman’s ability to push

primis

Mx:  Encourage & support her  Teach her pushing skills-i.e push with contiactions & rest (pant) in between the contiactions  But if there is no fetal distress assist to adopt alateral position & rest for about 30 minutes. Encourage change in positions e.g kneeling & upright position facilitate descend. 3 Rigid peaineum: 11

This inhibits descent of the felus during the peaineal phase

Mx: Perform an episiotomy under

L/A

4 Reduced pelvic outlet (Contiacted pelvis): Obstruction of labours at the pelvic outlet is usually caused by an andaoial pelvis due to prominent isehial spines and narrow Subpubic aceR.

Mx:

5 A



Ceasaean section



Forceps delivery

large felus

or

fetal malpresentation or malpositions of the

occiput: Labour will be prolonged and obstruction may occur at the pelvic brim,mid cavity or outlet.

Mx C/s Complications  Cystocele or Rectocele  Uterine prolapse

 Retension of urine  Infection  PIH/Eclampsia  Genital lacesatioas/tears  Foot drop 12

 V.V.F or R.V.F  Poor maternal outlook for future deliveries  Fetal intiaesanial haemosshages.

ABNORMAL LLABOUR ABOUR Compound Presentations Definition Is where an extremely prolepses alongside the presenting part, with both presenting in the pelvis simultaneously. Varieties I. Head + head (elbow cannot be felt) II. Head + arm (elbow can be felt) 13

III. Head + Foot IV. Head + More than one limb V. Rarely Breach + hand

Management A. Head plus a hand  The presence of a hand only alongside the presenting part (vertex in cephalic presentation) does not affect the outcome of labour.

 Monitor the progress and await spontaneous vaginal delivery. B. Head plus an arm Try to push the arm behind the head id this isn’t easy, stop trying difficult on prolonged manipulation cause and prolapsed Prepare the mother for c/s unless the fetus is very small.

C. Head plus foot Try to push the foot behind the head If this isn’t possible, prepare the mother for c/s. Note that the Doctor may pull the foot or push back the head. Breach presentation under G/F

D. Head plus more than one limb You should seldom try any manipulations

Prepare the mother for c/s

Complications 

Obstructed labour



Cold prolapsed/Presentation

INTRACRANIAL MEM MEMBRANES BRANES & SINUSES 14

THE FET FETAL AL SKULL -

The fetal skull contains the delicate brain which may be subjected to great pressure as the head passes through the pelvis at birth.

The fetal skull is larger in relation to the fetal body and in comparison with the true pelvic; therefore some adjustments must take place between skull and pelvis during birth. The fetal skull is larger in relation to the fetal body and in comparison with the true pelvis; therefore some adjustments must take place between skull and pelvis during birth. The head of the fetus is the most difficult to deliver whether it comes first or last. The facial bones are normally almost completely not completely ossified at birth leaving small gaps which from the sutures and fontanelles. The ossification centre on each bone appears as a boss or protuberance.

SUTURES & FONT FONTANELLES ANELLES Def: Suture Is a cranial joint and is formed where two bones meet Fontanelles Is a membranous space between two or more cranial bones

SUTURES Lambdoidal suture It separates the occiput from the two parietal bones Saggital suture Lies between the two parietal bones and between the lambda and bregma Coronal suture Lies between the two parietal bones and the frontal bones frontal suture Lies between the two halves of the frontal bones. At birth, at term, this suture is normally ossified.

FONT FONTANELLES ANELLES Lambanda Lambanda: 15

Is also known as posterior fontanelle . Its situated at the function of the lambidoidal suture and saggital suture. Characteristic of; 1 its small 2; Its triangular in shape 3;Itnormally closes by 6/52 of age Bregma Bregma; Is also known as anterior fontanelle. Its situated at the function of the saggital coronal and frontal sutures. Characteristic; 1;Its broad. 2;Kit shaped (diamond shaped) 3:It measure 3-4m long &1.5cm wide. 4.Closes when the child is 18/12 of age. 5; Pulsation of the cerebral vessels can be felt through it.

N/B; The suctures and fontanelles, because they consist of membranes spaces, allow a degree of overlapping of the skull bones during labour and delivery. This is termed

Moulding.

REGIONS & LLANDMARKS ANDMARKS OF THE FET FETAL AL SKULL

Regions; the skull is divided into; 1;; The vvault; ault; Is the large, dome shaped part above imaginary lines drawn from the orbital ridges and the nape of the neck.

2;The The base;Consist of the bones which are firmly united to protect the vital center in the medulla.

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3;The The fface;ace;Is made of 14 small bones which are firmly fused..

The regions of the skull are described as follows;-

The occiput;Lies between the foram...