Uterine rupture: preventable obstetric tragedies?

BACKGROUND: Although ruptured uterus is nowadays a rare obstetric emergency in Western countries, it is still alarmingly common in developing countries, where it remains a major cause of maternal mortality and morbidity.

AIMS: To review the recent experience of uterine rupture at a tertiary obstetric unit in eastern Nepal and to recommend improvements in the current management of labour, especially obstructed labour, in a poorly resourced country.

METHODS: All cases of uterine rupture managed from March 2002 to March 2006 were identified retrospectively, and details were retrieved from medical records.

RESULTS: Fifty-two women suffered from uterine rupture during the four-year period, approximately one woman per month. Most were unbooked multigravidae, with no antenatal care. They nearly all began labour at home in the absence of a skilled birth attendant. After prolonged labour, usually prolonged second stage, various interventions had often been attempted at home or in other health facilities before admission. Most were shocked and required urgent laparotomy and blood transfusion. Many required intensive care and ventilatory support. Forty-six per cent required hysterectomy and 5.8% subsequently suffered from a urogenital fistula. The maternal mortality rate in this series was 13.5%, and the stillbirth rate was 94.2%.

CONCLUSIONS: Unsafe obstetric practices were identified, especially the injudicious use of oxytocic drugs and fundal pressure in prolonged second stage. Several achievable improvements in obstetric care are recommended, particularly aimed at reducing the delay in women reaching emergency obstetric care when labour is prolonged.