Cesarean Delivery and Uterine Rupture

Cesarean delivery (CD) is the leading cause of uterine rupture. Performing a trial of labor after a previous CD (TOLAC) requires cautious consideration. Numerous studies reported perinatal outcomes of uterine rupture in heterogeneous populations, including cases of unscarred uteri, more than one previous CD, preterm deliveries, and cases occurring outside the delivery setting. There is a lack of data regarding studies addressing uterine rupture during a TOLAC.

In a selected population of women who experienced uterine rupture during a TOLAC in a singleton gestation at term with one prior CD, adverse perinatal outcomes are still of much concern, though possibly more favorable than previously described. There is no association between oxytocin use and worse perinatal outcomes in these cases, explains Amikam et al. and colleagues. This study was published in the International Journal of Gynecology and Obstetrics.

The optimal mode of delivery after one previous CD is much debated. Some studies show increased perinatal complications with a TOLAC, while others highlight its benefits.

In this retrospective single-centre study, researchers determined perinatal outcomes following uterine rupture during a trial of labor after one previous cesarean delivery (CD) at term. The primary and secondary outcomes were composite maternal and neonatal outcomes. They also compared perinatal outcomes between women who received oxytocin during delivery and those who did not.

Key Findings of the Study

• 6873 women attempted a TOLAC.
• One hundred sixteen women were diagnosed with uterine rupture. Among them, 63 women met the inclusion criteria.
• Eighteen women, constituting 28%, had the maternal composite outcome without any case of maternal death.
• Sixteen cases, constituting 25.4%, had the composite neonatal outcome, with one perinatal death recorded.
• There were no differences between women receiving oxytocin and those who did not in the rates of maternal composite (35.7% vs 26.5%) or neonatal composite outcomes (21.4% vs 26.5%).
• The rate of uterine rupture in those trying to achieve a VBAC was 0.96%. This was similar to what was described in previous research, with a range between 0.5% and 1%.
• Neonatal outcome was more favorable in this study compared to previous studies.
• The maternal outcome was favorable, with no cases of maternal death, a hysterectomy rate of 3.2%, and a lower blood transfusion rate. This could be due to the highly selective population in our study.

They wrote, “Our findings are reassuring to both physicians and patients, in as much as uterine rupture under oxytocin does not result in worse outcomes.”

Study Strengths and Limitations

Strengths of the study include strict inclusion criteria and exclusion of cases of incomplete uterine rupture or dehiscence due to their favorable prognosis. Limitations include a retrospective nature, small cohort size, and limited generalizability.

Reference

Amikam et al. Perinatal outcomes following uterine rupture during a trial of labor after cesarean: A 12‐year single-centre experience. International Journal of Gynaecology and Obstetrics. https://doi.org/10.1002/ijgo.15178