Obstetric anaesthesia14 / 17
Uterine rupture during trial of labour after caesarean30-year-old woman, 72 kg, at 40 weeks in labour after one previous caesarean
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Know this first
- Rupture risk in trial of labour after caesarean: 0.4–1%.
- An abnormal fetal heart tracing is the most reliable sign.
- Breakthrough pain occurs in only a minority, unrelated to the epidural.
- Obstetrician, anaesthetist and nursing staff immediately available throughout.
- Massive transfusion: balanced products, early fibrinogen, tranexamic acid.
The patient
30-year-old woman, 72 kg, at 40 weeks in labour after one previous caesarean, with an epidural working well for 4 hours.
Oxytocin augmentation started 2 hours ago; now 7 cm dilated.
Otherwise well; no regular drugs.
Vitals: BP 120/72, HR 90, SpO2 99% on air, RR 16.
The examiner asks
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Consider
What are the risks here?
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- A 30-year-old attempting vaginal birth after one caesarean, augmented, with a good epidural. Patient
- At term, a general anaesthetic in minutes means aspiration, airway and caval risks.
- Rupture risk is 0.4–1%, and excess oxytocin adds to it. Disease
- Obstetrician, anaesthetist and theatre must be immediately available throughout. Surgery
Plan
What is your plan during her labour?
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- Keep the epidural working well; it's my fast route to a caesarean. Disease
- Dilute solutions; a good block doesn't hide rupture, as fetal heart change is the key sign.
- New pain through a good block is a warning; I review her rather than just top up.
- Group and screen, a large cannula, and sodium citrate ready. Patient
Crisis
She suddenly has severe constant abdominal pain through the epidural; fetal heart 60/min, contractions stopped, the head has risen. BP 92/56, HR 120. What do you do?
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- Uterine rupture until proven otherwise: bradycardia, pain, lost contractions and lost station. (Crisis)
- Help called, category 1 laparotomy now; no investigations to delay delivery.
- Oxytocin off, two large-bore cannulas, blood sent for and products to theatre.
- She's dropping her pressure, so general rather than an epidural top-up.
- Rapid sequence: ketamine 1 mg/kg for her low pressure, rocuronium 1.0 mg/kg.
- Neonatal team to theatre.
Crisis
The baby is out; the uterus is torn into the broad ligament. Blood loss 3000 mL; BP 70/40, HR 145. What do you do?
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- Massive haemorrhage protocol activated, with balanced red cells, plasma and platelets. Crisis
- Tranexamic acid 1 g, run over 10 minutes.
- Early fibrinogen to 150–200 mg/dL; calcium replaced and everything warmed.
- Products through a rapid infuser; no crystalloid-only resuscitation.
- Arterial line and viscoelastic tests to guide us.
- Repair or hysterectomy is the surgeon's call; with this tear, hysterectomy is likely.
- ICU afterwards. After surgery
Fatal mistakes
- Treating breakthrough pain with more epidural and no review.
- Delaying delivery for investigations.
- Crystalloid-only resuscitation of massive bleeding.
Checked against: Miller 10e · Barash 9e
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