Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health

Equivalence between physicians and associate clinicians in the frequency of iatrogenic urogenital fistula following cesarean section in Tanzania and Malawi

BACKGROUND

Physicians and associate (non-physician) clinicians conduct cesarean sections in Tanzania and Malawi. Urogenital fistulas may occur as complications of cesarean section. Location and circumstances can indicate iatrogenic origin as opposed to ischemic injury following prolonged, obstructed labor.

METHODS

This retrospective review assessed the frequency of iatrogenic urogenital fistulas following cesarean sections conducted by either associate clinicians or physicians in Tanzania and Malawi. It focuses on 325 women with iatrogenic fistulas among 1290 women who had fistulas after cesarean birth in Tanzania and Malawi between 1994 and 2017. An equivalence test compared the proportion of iatrogenic fistulas after cesarean sections performed by associate clinicians and physicians (equivalence margin = 0.135). Logistic regression was used to model the occurrence of iatrogenic fistula after cesarean section, controlling for cadre, date, maternal age, previous abdominal surgery and parity.

RESULTS

Associate clinicians attended 1119/1290 (86.7%) cesarean births leading to fistulas, while physicians attended 171/1290 (13.3%). Iatrogenic fistulas occurred in 275/1119 (24.6%) cesarean births by associate clinicians and in 50/171 (29.2%) cesarean births by physicians. The risk difference and 90% confidence interval were entirely contained within an equivalence margin of 13.5%, supporting a conclusion of equivalence between the two cadres. The odds of iatrogenic fistula after cesarean section were not statistically significantly different between associate clinicians and physicians (aOR 0.90; 95% CI 0.61-1.33).

CONCLUSIONS

Associate clinicians appear equivalent to physicians performing cesarean sections in terms of iatrogenic fistula risk. Lower iatrogenic proportions for associate clinicians could reflect different caseloads. The occurrence of iatrogenic fistulas illustrates the importance of appropriate labor management and cesarean section decision-making, irrespective of health provider cadre. Given the noninferior performance and lower costs of employing associate clinicians, other countries with insufficient and/or unequally distributed health workforces could consider task-shifting cesarean sections to associate clinicians.

A rare case of uterine rupture in the first trimester of pregnancy: Case report and review of literature

Uterine rupture is a serious and potentially life-threatening complication. It is commonly a complication that happens in the third trimester of pregnancy. Its occurrence in early pregnancy is very rare. We report a case of a patient who presented with uterine rupture on a scarred uterus during the termination of pregnancy with misoprostol at 10 weeks' amenorrhea. In this case, we discuss the clinical warning signs, risk factors, and diagnostic methodology, and compare our approach with the literature.

Using Robson classification to analyze cesarean section and induction rates in relation to changes in the standards of perinatal care in one hospital in Poland

BACKGROUND

Poland has one of the highest cesarean birth (CB) rates in Europe. For this study, we used the Robson Ten-Group Classification System (TGCS) to analyze trends in the induction and CB rates in one hospital in Poland over a period of 11 years. We compare these trends with changes in National Legislative and Medical Guidelines introduced during this time that were aimed at lowering rates of unnecessary medical interventions.

METHODS

We conducted a retrospective study including all births after 24 weeks' gestation between 2010 and 2020 from one tertiary hospital (n = 66,716 births). After the deletion of records with missing data, 66,678 births were included in the analysis. All births were classified according to the Robson TGCS. The size, CB rate, and contribution of each group for every year were calculated. Linear regression analyses were used to analyze trends over time.

RESULTS

The total CB rate varied from 29.6% to 33.0% during the study period, with a linear increase of 0.045 percentage points annually (R2 = 0.021; F(1) = 0.189; p = 0.674). This study was considerably lower than the total CB rate for Poland, which rose from 33.9% in 2010 to 45.1% in 2020, increasing at a rate of 1.13 percentage points per year (R2 = 0.93; F(1) = 61.88; p < 0.001). Induction rates among both nulliparous (R1 + R2) and multiparous (R3 + R4) women at term also increased. Study groups R5 (previous cesarean birth), R2 (nulliparous in induced or prelabor cesarean delivery), and R1 (nulliparous women at term with single cephalic pregnancy in spontaneous labor) were the highest contributors to the overall CB rate. The greatest decrease in the CB rate was detected in group R5b (more than one previous CB). None of the groups showed statistically significant increases in CB rates over the study period.

CONCLUSIONS

The CB rate in the hospital where the study was conducted was considerably lower than the total CB rate in Poland. When compared with countries with similar CB rates, group R2b (women with nulliparous, prelabor cesarean birth) in our study was considerably larger. More comparisons across different hospital settings in Poland are needed. However, as hospitals are not encouraged to routinely collect the data needed to construct TGCS, such comparisons are very difficult to conduct.

Risk factors for maternal complications following uterine rupture: a 12-year single-center experience

PURPOSE

To determine maternal outcomes and risk factors for composite maternal morbidity following uterine rupture during pregnancy.

METHODS

A retrospective cohort study including all women diagnosed with uterine rupture during pregnancy, between 2011 and 2023, at a single-center. Patients with partial uterine rupture or dehiscence were excluded. We compared women who had composite maternal morbidity following uterine rupture to those without. Composite maternal morbidity was defined as any of the following: maternal death; hysterectomy; severe postpartum hemorrhage; disseminated intravascular coagulation; injury to adjacent organs; admission to the intensive care unit; or the need for relaparotomy. The primary outcome was risk factors associated with composite maternal morbidity following uterine rupture. The secondary outcome was the incidence of maternal and neonatal complications following uterine rupture.

RESULTS

During the study period, 147,037 women delivered. Of them, 120 were diagnosed with uterine rupture. Among these, 44 (36.7%) had composite maternal morbidity. There were no cases of maternal death and two cases of neonatal death (1.7%); packed cell transfusion was the major contributor to maternal morbidity [occurring in 36 patients (30%)]. Patients with composite maternal morbidity, compared to those without, were characterized by: increased maternal age (34.7 vs. 32.8 years, p = 0.03); lower gestational age at delivery (35 + 5 vs. 38 + 1 weeks, p = 0.01); a higher rate of unscarred uteri (22.7% vs. 2.6%, p < 0.01); and rupture occurring outside the lower uterine segment (52.3% vs. 10.5%, p < 0.01).

CONCLUSION

Uterine rupture entails increased risk for several adverse maternal outcomes, though possibly more favorable than previously described. Numerous risk factors for composite maternal morbidity following rupture exist and should be carefully assessed in these patients.

Perinatal outcomes following uterine rupture during a trial of labor after cesarean: A 12-year single-center experience

OBJECTIVE

To determine perinatal outcomes following uterine rupture during a trial of labor after one previous cesarean delivery (CD) at term.

METHODS

A retrospective single-center study examining perinatal outcomes in women with term singleton pregnancies with one prior CD, who underwent a trial of labor after cesarean (TOLAC) and were diagnosed with uterine rupture, between 2011 and 2022. The primary outcome was a composite maternal outcome, and the secondary outcome was a composite neonatal outcome. Additionally, we compared perinatal outcomes between patients receiving oxytocin during labor with those who did not.

RESULTS

Overall, 6873 women attempted a TOLAC, and 116 were diagnosed with uterine rupture. Among them, 63 (54.3%) met the inclusion criteria, and 18 (28%) had the maternal composite outcome, with no cases of maternal death. Sixteen cases (25.4%) had the composite neonatal outcome, with one case (1.6%) of perinatal death. No differences were noted between women receiving oxytocin and those not receiving oxytocin in the rates of maternal composite (35.7% vs 26.5%, P = 0.502, respectively) or neonatal composite outcomes (21.4% vs 26.5%, P = 0.699).

CONCLUSION

Uterine rupture during a TOLAC entails increased risk for myriad adverse outcomes for the mother and neonate, though possibly more favorable than previously described. Oxytocin use does not affect these risks.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Biomechanical Modeling of Cesarean Section Scars and Scar Defects

Uterine rupture is an intrinsically biomechanical process associated with high maternal and fetal mortality. A previous Cesarean section (C-section) is the main risk factor for uterine rupture in a subsequent pregnancy due to tissue failure at the scar region. Finite element modeling of the uterus and scar tissue presents a promising method to further understand and predict uterine ruptures. Using patient dimensions of an at-term uterus, a C-section scar was modeled with an applied intrauterine pressure to study how scars affect uterine stress. The scar positioning and uterine thickness were varied, and a defect was incorporated into the scar region. The modeled stress distributions confirmed clinical observations as the increased regions of stress due to scar positioning, thinning of the uterine walls, and the presence of a defect are consistent with clinical observations of features that increase the risk of uterine rupture.

Delivery after a previous cesarean section reviewed

At the start of the 20th century, cesarean section (CS) was uncommon in obstetrics. By the end of the century, CS rates had increased dramatically worldwide. Although the explanation for the increase is multifactorial, a major driver in the ongoing escalation is the increase in women who are delivered by repeat CS. This is due, in part, to the fact that there has been a sharp fall in vaginal birth after CS (VBAC) rates as fewer women are offered a trial of labor after CS (TOLAC), due principally to fears of a catastrophic intrapartum uterine rupture. This paper reviewed international VBAC policies and trends. A number of themes emerged. The risk of intrapartum rupture and its associated complications is low and may sometimes be overestimated. Individual maternity hospitals in both developed and developing countries are inadequately resourced to safely supervise a TOLAC. Efforts to mitigate the risks of TOLAC by careful patient selection and good clinical practices may be underutilized. Given the serious short-term and long-term consequences of rising CS rates for women and for maternity services generally, a review of TOLAC policies worldwide should be prioritized and consideration given to convening a Global Consensus Development Conference on Delivery after CS.

"It's complicated…": Exploring second stage caesarean sections and reasons for non-performance of assisted vaginal births in Kenya: A mixed methods study

Unnecessary Caesarean Section (CS) can have adverse effects on women and their newborns. Assisted vaginal birth/delivery (AVB/AVD) using a suction device or obstetric forceps is a potential alternative when delays or complications occur in the second stage of labour. Unlike CS, AVB using a suction device does not require regional or general anaesthesia, can often be performed by midwives, and does not scar the uterus, lowering the risk of maternal mortality and morbidity, in this and subsequent pregnancies. This study examined the appropriateness and outcomes of second stage CS (SSCS), and reasons for low levels of AVB use, in Kenya. Using a mixed methods study design, we reviewed case notes from women having SSCS births and AVB, and conducted key informant interviews with healthcare providers, from 8 purposively selected hospitals in Kenya. Randomly selected SSCS and all AVB case notes were reviewed by a panel of four experienced obstetricians, and appropriateness of the procedure assessed. Semi-structured interviews were conducted with obstetricians, medical officers and midwives, and analysed using a thematic approach. Review of 67 SSCS case notes showed 10% might have been conducted as AVBs, with a further 58% unable to be classified due to inadequate/inconsistent record keeping or excessive delay following initial CS decision. Outcomes following SSCS showed perinatal mortality rate of 89.6/1,000 births, with 11% of infants and 9% of mothers experiencing complications. Non-referred cases of AVB showed good outcomes. The findings of the 20 interviews explored the experience and confidence of healthcare providers in performing AVBs, and adequacy of the training they received. Key reasons for non-performance included lack of functioning equipment, lack of trained staff or their rotation to other departments. Reasons for non-performance of AVB were complex and often multiple. Any solutions to these problems will need to address various local, regional and national issues.

Conservative management of complete fetal expulsion into the abdominal cavity after silent uterine rupture - case report

BACKGROUND

Clinically silent uterine rupture with complete fetal expulsion into the abdominal cavity is an extremely rare complication. Diagnosis can be difficult and the risk to the mother and fetus is high. Conservative management has been described only in a few cases of partial expulsion of the fetus so far.

CASE PRESENTATION

We present a case of 43-year-old tercigravida with a history of previous laparotomic myomectomy and subsequent cesarean section. The subsequent pregnancy was complicated by uterine wall loosening and rupture at the site of the previous uterine scar after myomectomy and complete fetal expulsion into the abdominal cavity. The diagnosis was made at 24 + 6 weeks of gestation. Considering the absence of clinical symptomatology and the good condition of the fetus, a conservative approach was chosen with intensive monitoring of the maternal and fetal conditions. The pregnancy ended by elective cesarean section and hysterectomy at 28 + 0 weeks of gestation. The postpartum course was uneventful and the newborn was discharged to home care 63 days after delivery.

CONCLUSIONS

Fetal expulsion into the abdominal cavity after silent uterine rupture of the scarred uterus may be accompanied by minimal symptomatology making early diagnosis difficult. This rare complication must be considered in the differential diagnosis in women after major uterine surgery. In selected cases and under conditions of intensive maternal and fetal monitoring, conservative management may be chosen to reduce the risks associated with prematurity.

Unexpected Uterine Rupture-A Case Report, Review of the Literature and Clinical Suggestions

BACKGROUND AND OBJECTIVES

Women with a history of cesarean section are a high-risk group because they are likely to develop uterine rupture during their next pregnancy. Current evidence suggests that a vaginal birth after cesarean section (VBAC) is associated with lower maternal mortality and morbidity than elective repeat cesarean delivery (ERCD). Additionally, research suggests that uterine rupture can occur in 0.47% of cases of trial of labor after cesarean section (TOLAC).

CASE DESCRIPTION

A healthy 32-year-old woman at 41 weeks of gestation, in her fourth pregnancy, was admitted to the hospital due to a dubious CTG record. Following this, the patient gave birth vaginally, underwent a cesarean section, and successfully underwent a VBAC. Due to her advanced gestational age and favorable cervix, the patient qualified for a trial of vaginal labor (TOL). During labor induction, she displayed a pathological CTG pattern and presented symptoms such as abdominal pain and heavy vaginal bleeding. Suspecting a violent uterine rupture, an emergency cesarean section was performed. The presumed diagnosis was confirmed during the procedure-a full-thickness rupture of the pregnant uterus was found. The fetus was delivered without signs of life and successfully resuscitated after 3 min. The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at 1, 3, 5, and 10 min. The uterine wall rupture was closed with two layers of sutures. The patient was discharged 4 days after the cesarean section without significant complications, with a healthy newborn girl.

CONCLUSIONS

Uterine rupture is a rare but severe obstetric emergency and can be associated with maternal and neonatal fatal outcomes. The risk of uterine rupture during a TOLAC attempt should always be considered, even if it is a subsequent TOLAC.

Perinatal mortality rate and adverse perinatal outcomes presumably attributable to placental dysfunction in (near) term gestation: A nationwide 5-year cohort study

INTRODUCTION

Placental dysfunction can lead to perinatal hypoxic events including stillbirth. Unless there is overt severe fetal growth restriction, placental dysfunction is frequently not identified in (near) term pregnancy, particularly because fetal size is not necessarily small. This study aimed to evaluate, among (near) term births, the burden of hypoxia-related adverse perinatal outcomes reflected in an association with birth weight centiles as a proxy for placental function.

MATERIAL AND METHOD

A nationwide 5-year cohort of the Dutch national birth registry (PeriNed) including 684,938 singleton pregnancies between 36+0 and 41+6 weeks of gestation. Diabetes, congenital anomalies, chromosomal abnormalities and non-cephalic presentations at delivery were excluded. The main outcome was antenatal mortality rate according to birthweight centiles and gestational age. Secondary outcomes included perinatal hypoxia-related outcomes, including perinatal death and neonatal morbidity, analyzed according to birthweight centiles.

RESULTS

Between 2015 and 2019, 1,074 perinatal deaths (0.16%) occurred in the study population (n = 684,938), of which 727 (0.10%) antenatally. Of all antenatal- and perinatal deaths, 29.4% and 27.9% occurred in birthweights below the 10th centile. The incidence of perinatal hypoxia-related outcomes was highest in fetuses with lowest birthweight centiles (18.0%), falling gradually up to the 50th and 90th centile where the lowest rates of hypoxia-related outcomes (5.4%) were observed.

CONCLUSION

Perinatal hypoxia-related events have the highest incidence in the lowest birthweight centiles but are identifiable throughout the entire spectrum. In fact, the majority of the adverse outcome burden in absolute numbers occurs in the group with a birthweight above the 10th centile. We hypothesize that in most cases these events are attributable to reduced placental function. Additional diagnostic modalities that indicate placental dysfunction at (near) term gestation throughout all birth weight centiles are eagerly wanted.

Incidence, indications, and maternal outcomes of emergency peripartum hysterectomy at a tertiary hospital in Ethiopia: A retrospective review

OBJECTIVE

To determine the incidence, indications, and maternal outcomes of emergency peripartum hysterectomy (EPH) at a tertiary setting in Ethiopia.

MATERIALS AND METHODS

A 4-year retrospective review of EPH cases was conducted at St. Paul's Hospital Millennium Medical College (Ethiopia) from January 2016 to December 2019. Data were collected by reviewing maternal charts of EPH cases using a structured data extraction format. Stata Statistical Software, release 14, was used for data analysis. Frequency and percentages are used to present the significance of results.

RESULTS

Among 39 629 deliveries during the study period, there were 105 EPH, making the incidence rate 2.6 per 1000 deliveries. The common indications for EPH were uterine rupture (63/105; 60%), intractable uterine atony (23/105; 21.9%), and placenta accreta spectrum (14/105; 14.7%). The most common complications were anemia (85/105; 80.9%), puerperal fever (13/105; 12.4%), acute kidney injury (10/105; 9.5%), and relaparotomy (7/105; 6.7%).

CONCLUSION

The incidence of EPH observed in our institution is high. Appropriate patient selection for vaginal delivery and strict labor follow up with early intervention for labor abnormalities should be the guiding principles of optimal obstetrical care to alleviate the burden of uterine rupture.

Outcomes of Uterine Rupture in the Setting of the Unscarred Compared With the Scarred Uterus

Uterine rupture is a rare obstetric complication that is associated with maternal and neonatal morbidity and mortality. The aim of this study was to examine uterine rupture and its outcomes in the setting of the unscarred compared with the scarred uterus. A retrospective observational cohort study was performed examining all cases of uterine rupture in three tertiary care hospitals in Dublin, Ireland, over a 20-year period. The primary outcome was perinatal mortality rate with uterine rupture, which was 11.02% (95% CI 6.5-17.3). There was no significant difference in perinatal mortality between cases of scarred and unscarred uterine rupture. Unscarred uterine rupture was associated with higher maternal morbidity , defined as major obstetric hemorrhage or hysterectomy.

Case-control study on determinants of uterine rupture among mothers who gave birth at Hawassa University comprehensive specialized hospital

BACKGROUND

Uterine rupture is defined as tearing of the uterine wall during pregnancy or delivery. It can occur during pregnancy or labor and delivery. Rupture of the uterus is a catastrophic event resulting in the death of the baby, and severe maternal morbidity and mortality Despite different interventions done by stakeholders, it remained one of the leading public problems in developing countries like Ethiopia.

OBJECTIVE

This study assessed the prevalence and determinants of uterine rupture among mothers who gave birth at Hawassa University comprehensive specialized hospital from July 2015 to June 2020G.C.

METHOD

A case-control study was conducted by reviewing data from a total of 582 patient charts which include 194 cases and 388 controls with a case-to-control ratio of 1:2. Then the data was extracted using a pre-tested and structured data extraction sheet. Data were entered using Epi data 3.1 and exported to SPSS and analyzed using SPSS 20. The association between independent variables and uterine rupture was estimated using an odds ratio with 95% confidence intervals. The statistical significance of the association was declared at P-value < 0.05.

RESULT

There were a total of 22,586 deliveries and 247 confirmed cases of uterine rupture which makes the prevalence 1.09%. Lack of ANC (Ante-natal care) (AOR = 7.5; 95% CI: 1.9-30.3) inadequate ANC (AOR = 2.45; 95% CI: 1.1-5.57), gravidity ≥5 (AOR = 3.3; 95% CI: 1.36-8.12), obstructed labor (AOR = 38.3; 95% CI: 17.8-82.4) and fetal macrosomia (AOR = 8; 95% CI: 17.8-82.4) are variables which increase the odds of developing uterine rupture. Mothers without additional medical or obstetric conditions are more likely (AOR = 4.2; 95% CI: 2.1-8.65) to develop uterine rupture than mothers with additional medical or obstetric conditions.

CONCLUSION

The prevalence of uterine rupture is high in the study area. The study also revealed that a decrease in ANC follow-up, gravidity of ≥5, obstructed labor, and fetal weight of >4kg are significantly associated with uterine rupture. Improving the quality of ANC follow-up, intrapartum follow-up and proper estimation of fetal weight are recommended interventions from the study.

Term breech presentation vaginal births in Tibet: A retrospective analysis of 451 cases

Background

In high altitude areas, like Tibet, most fetuses in breech presentation at term are delivered vaginally owing to a variety of reasons, but this has not been published.

Objective

This study aimed to provide references and evidence for the delivery of breach presentation term fetuses in high altitude areas, through comparing and analyzing the data of full-term singleton fetuses with breech or cephalic presentation in Naqu People's Hospital, Tibet.

Study design

We retrospectively analyzed the clinical data of 451 breech presentation fetuses mentioned above over a period of 5  years (2016-2020). A total of 526 cephalic presentation fetuses' data within 3  months (1 June to 1 September 2020) of the same period were collected too. Statistics were compared and assembled on fetal mortality, Apgar scores, and severe neonatal complications for both planned cesarean section (CS) and vaginal delivery. In addition, we also analyzed the types of breech presentation, the second stage of labor, and damage to the maternal perineum during vaginal delivery.

Results

Among the 451 cases of breech presentation fetuses, 22 cases (4.9%) elected for CS and 429 cases (95.1%) elected for vaginal delivery. Of the women who chose vaginal trial labor, 17 cases underwent emergency CSs. The perinatal and neonatal mortality rate was 4.2% in the planned vaginal delivery group and the incidence of severe neonatal complications was 11.7% in the transvaginal group, no deaths were detected in the CS group. Among the 526 cephalic control groups with planned vaginal delivery, the perinatal and neonatal mortality was 1.5% (p = 0.012), and the incidence of severe neonatal complications was 1.9%. Among vaginal breech deliveries, most of them were complete breech presentation (61.17%). Among the 364 cases, the proportion of intact perinea was 45.1%, and first degree lacerations accounted for 40.7%.

Conclusion

In the Tibetan Plateau region, vaginal delivery was less safe than cephalic presentation fetuses for full-term breech presentation fetuses delivered in the lithotomy position. However, if dystocia or fetal distress can be identified in time and then encouraged to convert to cesarean, its safety will be greatly improved.

Lessons learned from the perinatal audit of uterine rupture in the Netherlands: A mixed‐method study

Background and Aims

To analyze outcomes of nationwide local audits of uterine rupture to draw lessons for clinical care.

Methods

Descriptive cohort study. Critical incident audit sessions within all local perinatal cooperation groups in the Netherlands. Women who sustained uterine rupture between January 1st, 2017 and December 31st, 2019.

Main Outcome Measures

Improvable factors, recommendations, and lessons learned for clinical care. Women's case histories were discussed in multidisciplinary perinatal audit sessions. Participants evaluated care against national and local clinical guidelines and common professional standards to identify improvable factors. Cases and outcomes were registered in a nationwide database.

Results

One hundred and fourteen women who sustained uterine rupture were discussed in local perinatal audit sessions by 40–60 participants on average: A total of 111 (97%) were multiparous of whom 107 (94%) had given birth by cesarean section in a previous pregnancy. The audit revealed 178 improvable factors and 200 recommendations. Six percent (N = 11) of the improvable factors were identified as very likely and 18% (N = 32) as likely to have a relationship with the outcome or occurrence of uterine rupture. Improvable factors were related to inadequate communication, absent, or unclear documentation, delay in diagnosing the rupture, and suboptimal management of labor. Speak up in case a suspicion arises, escalating care by involving specialist obstetricians, addressing the importance of accurate documentation, and improving training related to fetal monitoring were the most frequent recommendations and should be topics for team (skills and drills) training.

Conclusions

Through a nationwide incident audit of uterine rupture, we identified improvable factors related to communication, documentation, and organization of care. Lessons learned include “speaking up,” improving the transfer of information and team training are crucial to reduce the incidence of uterine rupture.

Pregnancy complications and risk of uterine rupture among women with singleton pregnancies in China

BACKGROUND

The goal of this study was to investigate whether pregnancy complications are associated with an increased risk of uterine rupture (UR) and how that risk changes with gestational age.

METHODS

We obtained all data from China's National Maternal Near Miss Surveillance System (NMNMSS) between 2012 and 2018. Poisson regression analysis was used to assess the risk of UR with pregnancy complications (preeclampsia, gestational diabetes mellitus, placental abruption, placenta previa and placenta percreta) among 9,454,239 pregnant women. Furthermore, we analysed the risks of UR with pregnancy complications in different gestational age groups.

RESULTS

The risk of UR was increased 2.0-fold (1.2-fold to 2.7-fold) in women with pregnancy complications (except for preeclampsia). These associations also persisted in women without a previous caesarean delivery. Moreover, an increased risk of UR before term birth was observed among women with gestational diabetes mellitus, placental abruption and placenta percreta. The risk of UR was slightly higher in women with gestational diabetes mellitus who had a large for gestational age (LGA) foetus, especially at 32 to 36 weeks gestation.

CONCLUSIONS

The risk of UR is associated with gestational diabetes mellitus, placental abruption, placenta previa and placenta percreta, but varies in different gestational ages.

Correlation Between Previous Caesarean Section and Adverse Maternal Outcomes Accordingly With Robson Classification: Systematic Review and Meta-Analysis

Background: The increasing rates of Caesarean section (CS) beyond the WHO standards (10–15%) pose a significant global health concern.

Objective: Systematic review and meta-analysis to identify an association between CS history and maternal adverse outcomes for the subsequent pregnancy and delivery among women classified in Robson classification (RC).

Search Strategy: PubMed/Medline, EbscoHost, ProQuest, Embase, Web of Science, BIOSIS, MEDLINE, and Russian Science Citation Index databases were searched from 2008 to 2018.

Selection Criteria: Based on Robson classification, studies reporting one or more of the 14 adverse maternal outcomes were considered eligible for this review.

Data Collection: Study design data, interventions used, CS history, and adverse maternal outcomes were extracted.

Main Results: From 4,084 studies, 28 (n = 1,524,695 women) met the inclusion criteria. RC group 5 showed the highest proportion among deliveries followed by RC10, RC7, and RC8 (67.71, 32.27, 0.02, and 0.001%). Among adverse maternal outcomes, hysterectomy had the highest association after preterm delivery OR = 3.39 (95% CI 1.56–7.36), followed by Severe Maternal Outcomes OR = 2.95 (95% CI 1.00–8.67). We identified over one and a half million pregnant women, of whom the majority were found to belong to RC group 5.

Conclusions: Previous CS was observed to be associated with adverse maternal outcomes for the subsequent pregnancies. CS rates need to be monitored given the prospective risks which may occur for maternal and child health in subsequent births.

Pregnancy outcomes and associated factors for uterine rupture: an 8 years population-based retrospective study

Background

Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. The aim of this study was to assess the incidence of uterine rupture, its association with previous uterine surgery and vaginal birth after caesarean section (VBAC), and the maternal and perinatal implications.

Methods

This is a population-based retrospective study. All pregnant women treated for ruptured uterus in one center between 2013 and 2020 were included. Their information retrieved from the medical records department were reviewed retrospectively.

Results

A total of 209,112 deliveries were included and 41 cases of uterine rupture were identified. The incidence of uterine rupture was 1.96/10000 births. Among the 41 cases, 16 (39.0%) had maternal and fetal complications. There were no maternal deaths secondary to uterine rupture, while perinatal fatality related to uterine rupture was 7.3%. Among all cases, 38 (92.7%) were scarred uterus and 3 (7.3%) were unscarred uterus. The most common cause of uterine rupture was previous cesarean section, while cases with a history of laparoscopic myomectomy were more likely to have serious adverse outcomes, such as fetal death. 24 (59.0%) of the ruptures occurred in anterior lower uterine segment. Changes in Fetal heart rate monitoring were the most reliable signs for rupture.

Conclusions

Incidence of uterine rupture in the study area, Shanghai, China was consistent with developed countries. Further improvements in obstetric care and enhanced collaboration with referring health facilities were needed to ensure maternal and perinatal safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04415-6.

Risk Factors Associated with Uterine Rupture and Dehiscence: A Cross-Sectional Canadian Study

OBJECTIVE

 To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence.

METHODS

 Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada.

RESULTS

 There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p = 0.02), elevated maternal body mass index (BMI; OR: 3.4; p = 0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p = 0.05) and 5-minute low Apgar score (OR: 5.9; p < 0.001). Uterine rupture was associated with preterm deliveries (36.5 ± 4.9 versus 38.2 ± 2.9; p = 0.006), postpartum hemorrhage (OR: 13.9; p < 0.001), hysterectomy (OR: 23.0; p = 0.002), and stillbirth (OR: 8.2; p < 0.001). There were no associations between uterine rupture and maternal age, gestational age, onset of labor, spontaneous or artificial rupture of membranes, use of oxytocin, type of uterine incision, and birthweight.

CONCLUSION

 This large cohort demonstrated that there are different risk factors associated with either uterine rupture or dehiscence. Uterine rupture still represents a great threat to fetal-maternal health and, differently from the common belief, uterine dehiscence can also compromise perinatal outcomes.

Epidemiology of uterine rupture among pregnant women in China and development of a risk prediction model: analysis of data from a multicentre, cross-sectional study

OBJECTIVES

To describe the epidemiology of uterine rupture in China from 2015 to 2016 and to build a prediction model for uterine rupture in women with a scarred uterus.

SETTING

A multicentre cross-sectional survey conducted in 96 hospitals across China in 2015-2016.

PARTICIPANTS

Our survey initially included 77 789 birth records from hospitals with 1000 or more deliveries per year. We excluded 2567 births less than 24 gestational weeks or unknown and 1042 births with unknown status of uterine rupture, leaving 74 180 births for the final analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Complete and incomplete uterine rupture and the risk factors, and a prediction model for uterine rupture in women with scarred uterus (assigned each birth a weight based on the sampling frame).

RESULTS

The weighted incidence of uterine rupture was 0.18% (95% CI 0.05% to 0.23%) in our study population during 2015 and 2016. The weighted incidence of uterine rupture in women with scarred and intact uterus was 0.79% (95% CI 0.63% to 0.91%) and 0.05% (95% CI 0.02% to 0.13%), respectively. Younger or older maternal age, prepregnancy diabetes, overweight or obesity, complications during pregnancy (hypertensive disorders in pregnancy and gestational diabetes), low education, repeat caesarean section (≥2), multiple abortions (≥2), assisted reproductive technology, placenta previa, induce labour, fetal malpresentation, multiple pregnancy, anaemia, high parity and antepartum stillbirth were associated with an increased risk of uterine rupture. The prediction model including eight variables (OR >1.5) yielded an area under the curve (AUC) of 0.812 (95% CI 0.793 to 0.836) in predicting uterine rupture in women with scarred uterus with sensitivity and specificity of 77.2% and 69.8%, respectively.

CONCLUSIONS

The incidence of uterine rupture was 0.18% in this population in 2015-2016. The predictive model based on eight easily available variables had a moderate predictive value in predicting uterine rupture in women with scarred uterus. Strategies based on predictions may be considered to further reduce the burden of uterine rupture in China.

Online survey on uterotomy closure techniques in caesarean section

OBJECTIVES

Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications.

METHODS

The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively.

RESULTS

The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques.

CONCLUSIONS

There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications in subsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.

Evidence around early induction of labor in women of advanced maternal age and those using assisted reproductive technology

Worldwide, there has been a trend toward later motherhood. Concurrently, the incidence of subfertility has been on the rise, necessitating conception using assisted reproductive technologies (ARTs). These pregnancies are considered high risk due to fetal complications such as antepartum stillbirth and growth restriction and maternal complications such as increase in maternal morbidity and mortality. Early induction of labor can help to mitigate these risks. However, this has to be balanced against the iatrogenic harms of earlier delivery to both the baby, including respiratory distress and NICU stay, and the mother who might experience longer labor and other complications such as uterine hyperstimulation. Induction of labor at 39 weeks is the optimal timing for preventing antepartum stillbirth and avoiding iatrogenic harm. Delivery by elective cesarean section is not advocated as its benefits in these patients are unclear compared with the short- and long-term complications of a major abdominal surgery.

Non-haemorrhagic uterine rupture at 28 weeks of pregnancy following previous caesarean section: a case report

Background

There is need to put forward more symptoms and signs that could suggest a diagnosis of uterine rupture so that clinicians’ suspicion is increased; there is also need to put forward uncommon intraoperative findings in patients with uterine rupture to correlate with the signs and symptoms of patients.

Case presentation

A 33 year old Gravida 5 Para 4 + 0 with 2 previous caesarean section scars at 28 weeks of amenorrhoea, presented to hospital complaining of lower abdominal pain for 11 h. She had no vaginal bleeding or vaginal discharge or pain on passing urine. On examination she had no pallor, pulse rate was 84 bpm, blood pressure was 110/80 mm of mercury (mmHg), fundal height was 27 cm (cm), fetal heart rate was regular at 150 beats per minute (bpm) and her cervix had a parous os. She was diagnosed with preterm labour and given dexamethasone intramuscularly, then an obstetric ultrasound scan was done and it revealed severe oligohydramnios. Decision do deliver her by emergency caesarean section was made and intraoperative findings were of a uterine rupture along the uterine scar with a fetal arm protruding through and vernix caseosa in the peritoneal cavity, without active uterine bleeding. The patient recovered well postoperatively.

Conclusions

There is need to suspect uterine rupture in pregnant women with previous caesarean section scars if they present with abdominal pain and are found to have severe oligohydramnios despite having no history of any vaginal discharge, even when the fetal heart rate is normal and they are haemodynamically stable and without vaginal bleeding and remote from term.

Determinants of uterine rupture among mothers who gave birth in Jinka and Arba Minch General Hospitals, institution-based case-control study, Southern Ethiopia, Ethiopia, 2019

Background:

Uterine rupture is a major public health problem in low-income countries including Ethiopia. In Ethiopia, its prevalence is low, but it results in devastative health problems of the mother and her baby. Even though the Ethiopian government and nongovernmental organizations tried to strengthen the health care system, significant adverse maternal and fetal outcome is still associated with uterine rupture. The aim of this study was to identify determinants of uterine rupture in Jinka and Arba Minch General Hospitals.

Methods:

The study was conducted in Jinka and Arba Minch General Hospitals, and the data collection period was 15 to 30 November 2018. A case–control study design was used with simple random sampling of 1:4. Data were collected using data extraction sheets. Variables with p < 0.25 in bivariate logistic regression were entered into multivariable logistic regression. Variables with p < 0.05 in multivariable logistic regression were used to determine significant association between dependent and independent variables.

Result:

Uterine rupture occurred in 112 cases with 448 controls. Women referred from health facilities (adjusted odds ratio = 8.0, 95% confidence interval: 3.5–17.8), multiparous women (adjusted odds ratio = 12.7, 95% confidence interval: 4.2–39.0), duration of labor more than 18 h (adjusted odds ratio = 11.5, 95% confidence interval: 5.5–24.1), malpresentation (adjusted odds ratio = 3.5, 95% confidence interval: 1.0–8.0) and gestational age of ⩾37 weeks (adjusted odds ratio = 5.2, 95% confidence interval: 1.4–19.3) were independent factors associated with uterine rupture.

Conclusion:

Mothers referred from health facilities, multiparous women, duration of labor more than 18 h, gestational age of ⩾37 weeks and malpresentation were significantly associated with uterine rupture. Early referral, encouraging family planning, proper use of partograph, early identification and appropriate intervention for malpresentation are recommended.

The incidence, risk factors and maternal and foetal outcomes of uterine rupture during different birth policy periods: an observational study in China

Background

Currently, there are no studies on changes in the incidence of uterine rupture or maternal and foetal outcomes in women with uterine rupture during different birth policy periods in China. Moreover, the results of association studies of maternal age, parity and previous caesarean section number with the risk of maternal and foetal outcomes in women with uterine rupture have not been consistent. This research aims to conduct and discuss the above two aspects.

Methods

We included singleton pregnant women with no maternal complications other than uterine rupture from January 2012 to June 2019 in China’s National Maternal Near Miss Surveillance System. The data in this study did not differentiate between complete and partial uterine rupture and uterine dehiscence. Through Poisson regression analysis with a robust variance estimator, we compared the incidences of uterine rupture and maternal and foetal outcomes in women with uterine rupture during different birth policy periods in China and determined the relationship between maternal age, parity or previous caesarean section number and uterine rupture or maternal and foetal outcomes in women with uterine rupture.

Results

This study included 8,637,723 pregnant women. The total incidences of uterine rupture were 0.13% (12,934) overall, 0.05% during the one-child policy, 0.12% during the partial two-child policy (aRR = 1.96; 95% CI: 1.53–2.52) and 0.22% (aRR = 2.89; 95% CI: 1.94 4.29) during the universal two-child policy. The maternal near miss and stillbirth rates in women with uterine rupture were respectively 2.35% (aRR = 17.90; 95% CI: 11.81–27.13) and 2.12% (aRR = 4.10; 95% CI: 3.19 5.26) overall, 5.46 and 8.18% during the first policy, 1.72% (aRR = 0.60; 95% CI: 0.32–1.17) and 2.02% (aRR = 0.57; 95% CI: 0.37–0.83) during the second policy, and 1.99% (aRR = 0.90; 95% CI: 0.52–1.53) and 1.04% (aRR = 0.36; 95% CI: 0.24–0.54) during the third policy. The risk of uterine rupture increased with parity and previous caesarean section number.

Conclusion

The uterine rupture rate in China continues to increase among different birth policy periods, and the risk of maternal near miss among women with uterine rupture has not significantly improved. The Chinese government, obstetricians, and scholars should work together to reverse the rising rate of uterine rupture and improve the pregnancy outcomes in women with uterine rupture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03811-8.

Maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation in Ethiopia: A systematic review and meta-analysis

Background

Uterine rupture is the leading cause of maternal and perinatal morbidity and it accounts for 36% of the maternal mortality in Ethiopia. The maternal and perinatal outcomes of uterine rupture were inconclusive for the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled maternal and perinatal mortality and morbidity of uterine rupture and its association with prolonged duration of operation.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used for this systematic review and meta-analysis. We systematically used PubMed, Cochrane Library, and African Journals online databases for searching. The Newcastle- Ottawa quality assessment scale was used for critical appraisal. Egger’s test and I² statistic used to assess the check for publication bias and heterogeneity. The random-effect model was used to estimate the pooled prevalence and odds ratios with 95% confidence interval (CI).

Results

The pooled maternal mortality and morbidity due to uterine rupture in Ethiopia was 7.75% (95% CI: 4.14, 11.36) and 37.1% (95% CI: 8.44, 65.8), respectively. The highest maternal mortality occurred in Southern region (8.91%) and shock was the commonest maternal morbidity (24.43%) due to uterine rupture. The pooled perinatal death associated with uterine rupture was 86.1% (95% CI: 83.4, 89.9). The highest prevalence of perinatal death was observed in Amhara region (91.36%) and the lowest occurred in Tigray region (78.25%). Prolonged duration of operation was a significant predictor of maternal morbidity (OR = 1.39; 95% CI: 1.06, 1.81).

Conclusions

The percentage of maternal and perinatal deaths due to uterine rupture was high in Ethiopia. Uterine rupture was associated with maternal morbidity and prolonged duration of the operation was found to be associated with maternal morbidities. Therefore, birth preparedness and complication readiness plan, early referral and improving the duration of operation are recommended to improve maternal and perinatal outcomes of uterine rupture.

Uterine Dehiscence and Subsequent Pregnancy Management: A Review of the Literature

Importance

Uterine dehiscence is a separation of the uterine musculature with intact uterine serosa. Uterine dehiscence can be encountered at the time of cesarean delivery, be suspected on obstetric ultrasound, or be diagnosed in between pregnancies. Management is a conundrum for obstetricians, regardless of timing of onset.

Evidence Acquisition

A literature search was undertaken by our research librarian using the search engines PubMed, CINAHL, and Web of Science. The search term used was "uterine dehiscence." The search was limited to the English language, and there was no limit on the years searched.

Results

The search identified 152 articles, 32 of which are the basis for this review. Risk factors, treatment, and management in subsequent pregnancies are discussed. The number of prior cesarean deliveries is the greatest risk factor for uterine dehiscence. Unrepaired uterine dehiscence can cause symptoms outside of pregnancies and may require repair for alleviation of these symptoms. Dehiscence should also be repaired prior to subsequent pregnancies.

Conclusion and Relevance

Planned delivery prior to the onset of labor with careful monitoring of maternal symptoms is the preferred management strategy of women with prior uterine dehiscence. Careful attention should be paid to the lower uterine segment thickness when ultrasonography is performed in women with prior cesarean delivery.

Relevance Statement

An evidence-based review of uterine dehiscence in pregnancy and how to manage subsequent pregnancies following uterine dehiscence.

Recovery of uterine and ovarian function in patients with complete placenta previa after caesarean delivery: A retrospective study

This retrospective study was designed to explore the recovery of uterine and ovarian function in patients with complete placenta previa (PP) after caesarean delivery (CD). 136 complete placenta previa patients (group completed placenta previa) and 140 patients without complete PP (group non-PP, control group) were included in this study from Jan 2016 to Dec 2018. Subgroup analysis of patients with complete PP was made to determine the impact of different hemostatic methods used during CD on the recovery of uterine function. There were no statistically significant differences between the 2 groups in postpartum menstrual cycle changes, ovarian hormone, and uterine vascular supply as measured by pulsatility index and systolic/diastolic ratio (P > .05). However, the group with complete PP had a reduced endometrial thickness (0.47 ± 0.11 vs 0.50 ± 0.12, P < .001), a lower uterine resistance index at 42nd days (0.84 ± 0.03 vs 0.90 ± 0.03, P < .001), and a delayed resumption menstruation (7.07 ± 2.61 vs 5.31 ± 2.16, P < .001) when compared with control group. Subgroup analysis showed that RI index of all subgroups in completed PP group was lower, endometrial thickness was thinner and the time to menstrual recovery was longer than that of non-PP group. In conclusion, the endometrial thickness and blood supply at 42nd days, not ovarian function, maybe affected after CD in patients with complete PP.

Burden of Uterine Rupture and Its Determinant Factors in Ethiopia: A Systematic Review and Meta-analysis

Background. Uterine rupture is a life-threatening obstetrical emergency, which results in serious undesired maternal and perinatal complications in resource-limited countries, mainly in Ethiopia. The prevalence, determinants, and outcomes of uterine rupture described by different studies were highly inconsistent in Ethiopia. Therefore, this systematic review and meta-analysis is aimed at estimating the pooled prevalence, determinants, and adverse outcomes of uterine rupture in Ethiopia. Methods. Studies were searched from international databases (PubMed/MEDLINE, HINARI, Cochrane library, Google Scholar, and web of science) and Ethiopian universities’ digital libraries (Addis Ababa University, University of Gondar, and Harameya University). All observational studies were included. A total of 15 studies that fulfill the inclusion criteria were included in this meta-analysis. Data were extracted by two reviewers and exported to STATA version 11 for analysis. The $I^2$ statistics were used to assess heterogeneity across the studies. Publication bias was examined by using Egger’s test and funnel plot. The pooled prevalence of uterine rupture and its outcomes were estimated by using a random effects model. The associations between determinants and uterine rupture were evaluated by using both random and fixed-effect models. Results. In this meta-analysis, a total of 15 studies with 92,394 study participants were involved. The pooled prevalence of uterine rupture was 2.37% in Ethiopia. Obstructed labor ( $\text{OR}=3.03$ ; $95\%\text{CI}=2.52,3.63$ ), lack of antenatal care follow-up ( $\text{OR}=5.79$ ; $95\%\text{CI}=2.47,13.61$ ), duration of $\text{labor}>24$ hours ( $\text{OR}=3.75$ ; $95\%\text{CI}=2.24,6.29$ ), grand multipara ( $\text{OR}=10.79$ ; $95\%\text{CI}=4.77,24.40$ ), and being rural residency ( $\text{OR}=7.17$ ; $95\%\text{CI}=3.90,13.16$ ) were significantly associated with uterine rupture. Conclusion. The overall prevalence of uterine rupture was high in Ethiopia. Obstructed labor, lack of antenatal care follow-up, duration of $\text{labor}>24$ hours, grand multipara, and rural residency were determinants of uterine rupture. This study implies the need to develop plans and policies to improve antenatal care follow-up and labor and delivery management at each level of the health system.

Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and meta-analysis

Background

Uterine rupture has a significant public health importance, contributing to 13% of maternal mortality and 74%-92% of perinatal mortality in Sub-Saharan Africa, and 36% of maternal mortality in Ethiopia. The prevalence and predictors of uterine rupture were highly variable and inconclusive across studies in the country. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence and predictor of uterine rupture in Ethiopia.

Methods

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist. PubMed, Cochrane Library, Google Scholar, and African Journals Online databases were searched. The Newcastle- Ottawa quality assessment tool was used for critical appraisal. I² statistic and Egger’s tests were used to assess the heterogeneity and publication bias, respectively. The random-effects model was used to estimate the pooled prevalence and odds ratios with a 95% confidence interval.

Results

Sixteen studies were included, with a total of 91,784 women in the meta-analysis. The pooled prevalence of uterine rupture was 2% (95% CI: 1.99, 3.01). The highest prevalence was observed in the Amhara regional state (5%) and the lowest was in Tigray region (1%). Previous cesarean delivery (OR = 9.95, 95% CI: 3.09, 32.0), lack of antenatal care visit (OR = 8.40, 95% CI: 4.5, 15.7), rural residence (OR = 4.75, 95% CI: 1.17, 19.3), grand multiparity (OR = 4.49, 95% CI: 2.83, 7.11) and obstructed labor (OR = 6.75, 95%CI: 1.92, 23.8) were predictors of uterine rupture.

Conclusion

Uterine rupture is still high in Ethiopia. Therefore, proper auditing on the appropriateness of cesarean section and proper labor monitoring, improving antenatal care visit, and birth preparedness and complication readiness plan are needed. Moreover, early referral and family planning utilization are the recommended interventions to reduce the burden of uterine rupture among Ethiopia women.

The association between birth by cesarean section and adolescent cardiorespiratory fitness in a cohort of 339,451 Swedish males

Birth by cesarean section is increasing worldwide and associates with offspring morbidities capable of adversely impacting cardiorespiratory fitness later in life. Whether birth by cesarean section associates with lower levels of cardiorespiratory fitness later in life is unknown and is of interest to public health. Four Swedish national registers were linked to follow 339,451 singleton males, born between 1973–1987 until December 31 2005, for Watt-maximum achieved on a cycle ergometer test at conscription into the Swedish military. Main exposure was birth by cesarean section which was compared to vaginal birth. A sub-population of 45,999 males born between 1982–1987 was identified to explore differentiated associations between elective and non-elective cesarean section with Watt-maximum. Within-family analyses of 34,252 families with 70,632 biological male siblings, who conscripted during the study period, were performed to explore the role of familial confounding on Watt-maximum. Swedish males born by cesarean section achieved lower mean Watt-maximum (− 2.32 W, 95%C.I. − 2.90 to − 1.75) and displayed excess odds of low cardiorespiratory fitness (aOR = 1.08, 95%C.I. 1.05 to 1.11) at conscription in the eighteenth life-year compared to males born vaginally after adjusting for birth characteristics, maternal morbidities and parental socioeconomic position. In the sub-population, males born 1982–1987, there was a greater negative association of elective cesarean section with cardiorespiratory fitness (− 4.42 W, 95%C.I. − 6.27 to − 2.57, p < 0.001) than non-elective cesarean sections (− 1.96 W, 95%C.I. − 3.77 to − 0.16, p = 0.033) as compared to vaginal births. No associations between modes of cesarean delivery and cardiorespiratory fitness levels persisted in the within-family analyses where biological male siblings were compared whilst controlling for factors shared within families. Males born by cesarean section had lower levels of cardiorespiratory fitness eighteen years later compared to males born vaginally. These findings appear to be largely explained by factors of familial confounding.

Prevalence and determinants of uterine rupture in Ethiopia: a systematic review and meta-analysis

Uterine rupture is a serious public health concern that causes high maternal and perinatal morbidity and mortality in the developing world. Few of the studies conducted in Ethiopia show a high discrepancy in the prevalence of uterine rupture, which ranges between 1.6 and 16.7%. There also lacks a national study on this issue in Ethiopia. This systematic and meta-analysis, therefore, was conducted to assess the prevalence and determinants of uterine rupture in Ethiopia. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic review and meta-analysis of studies. All observational published studies were retrieved using relevant search terms in Google scholar, African Journals Online, CINHAL, HINARI, Science Direct, Cochrane Library, EMBASE and PubMed (Medline) databases. Newcastle–Ottawa assessment checklist for observational studies was used for critical appraisal of the included articles. The meta-analysis was done with STATA version 14 software. The I² test statistics were used to assess heterogeneity among included studies, and publication bias was assessed using Begg's and Egger's tests. Odds ratio (OR) with a 95% confidence interval (CI) was presented using forest plots. A total of twelve studies were included in this study. The pooled prevalence of uterine rupture was 3.98% (95% CI 3.02, 4.95). The highest (7.82%) and lowest (1.53%) prevalence were identified in Amhara and Southern Nations, Nationality and Peoples Region (SNNPR), respectively. Determinants of uterine rupture were urban residence (OR = 0.15 (95% CI 0.09, 0.23)), primipara (OR = 0.12 (95% CI 0.06, 0.27)), previous cesarean section (OR = 3.23 (95% CI 2.12, 4.92)), obstructed labor(OR = 12.21 (95% CI 6.01, 24.82)), and partograph utilization (OR = 0.12 (95% CI 0.09, 0.17)). Almost one in twenty-five mothers had uterine rupture in Ethiopia. Urban residence, primiparity, previous cesarean section, obstructed labor and partograph utilization were significantly associated with uterine rupture. Therefore, intervention programs should address the identified factors to reduce the prevalence of uterine rupture.

Socioeconomic differences in caesarean section - are they explained by medical need? An analysis of patient record data of a large Kenyan hospital

BACKGROUND

Caesarean section (C-section) rates are often low among the poor and very high among the better-off in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context.

METHODS

We analyzed electronic records of 12,209 women who gave birth in a teaching hospital in Kenya in 2014. C-section rates were calculated by socioeconomic position (SEP), using maternal occupation (professional, small business, housewife, student) as indicator. We assessed if women had documented clinical indications according to hospital guidelines and if socioeconomic differences in C-section rates were explained by indication.

RESULTS

Indication for C-section according to hospital guidelines was more prevalent among professionals than housewives (16% vs. 9% of all births). The C-section rate was also higher among professionals than housewives (21.1% vs. 15.8% [OR 1.43; 95%CI 1.23-1.65]). This C-section rate difference was largely explained by indication (4.7 of the 5.3 percentage point difference between professionals and housewives concerned indicated C-sections, often with previous C-section as indication). Repeat C-sections were near-universal (99%). 43% of primary C-sections had no documented indication. Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate.

CONCLUSIONS

Socioeconomic differences in C-section rates can be largely explained by unnecessary primary C-sections and higher supposed need due to previous C-section. Prevention of unnecessary primary C-sections and promoting safe trial of labor should be priorities in addressing C-section over-use and reducing inequalities. Unnecessary primary C-sections and ubiquitous repeat C-sections drive overall C-section rates and C-section inequalities.

The role of extracellular matrix in normal and pathological pregnancy: Future applications of microphysiological systems in reproductive medicine

IMPACT STATEMENT

Extracellular matrix in the womb regulates the initiation, progression, and completion of a healthy pregnancy. The composition and physical properties of extracellular matrix in the uterus and at the maternal-fetal interface are remodeled at each gestational stage, while maladaptive matrix remodeling results in obstetric disease. As in vitro models of uterine and placental tissues, including micro-and milli-scale versions of these organs on chips, are developed to overcome the inherent limitations of studying human development in vivo, we can isolate the influence of cellular and extracellular components in healthy and pathological pregnancies. By understanding and recreating key aspects of the extracellular microenvironment at the maternal-fetal interface, we can engineer microphysiological systems to improve assisted reproduction, obstetric disease treatment, and prenatal drug safety.

Women's experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia

BACKGROUND

Vaginal birth after caesarean (VBAC) is a safe mode of birth for most women but internationally VBAC rates remain low. In Australia women planning a VBAC may experience different models of care including continuity of care (CoC). There are a limited number of studies exploring the impact and influence of CoC on women's experiences of planning a VBAC. Continuity of care (CoC) with a midwife has been found to increase spontaneous vaginal birth and decrease some interventions. Women planning a VBAC prefer and benefit from CoC with a known care provider. This study aimed to explore the influence, and impact, of continuity of care on women's experiences when planning a VBAC in Australia.

METHODS

The Australian VBAC survey was designed and distributed via social media. Outcomes and experiences of women who had planned a VBAC in the past 5 years were compared by model of care. Standard fragmented maternity care was compared to continuity of care with a midwife or doctor.

RESULTS

In total, 490 women completed the survey and respondents came from every State and Territory in Australia. Women who had CoC with a midwife were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC. Women who had CoC with a midwife were more likely to have been active in labour, experience water immersion and have an upright birthing position. Women who received fragmented care experienced lower autonomy and lower respect compared to CoC.

CONCLUSION

This study recruited a non-probability based, self-selected, sample of women using social media. Women found having a VBAC less traumatic than their previous caesarean and women planning a VBAC benefited from CoC models, particularly midwifery continuity of care. Women seeking VBAC are often excluded from these models as they are considered to have risk factors. There needs to be a focus on increasing shared belief and confidence in VBAC across professions and an expansion of midwifery led continuity of care models for women seeking a VBAC.

Successful Pregnancy after Previous Uterine Rupture

Uterine rupture is a rare and catastrophic incidence with high maternal and fetal morbidity rates. It is most commonly seen in the scarred uterus. The unscarred uterus is least susceptible to rupture with the incidencebeing 1 in 8000 deliveries. In the past, pregnancy after uterine rupture was not widely advised and patients underwent hysterectomy or tubal ligation but with the evolving practice, women are motivated for pregnancy which can be successful with proper obstetric care and emphasis on time and mode of delivery. Here we present a case of 31 years old female, gravida-2 para-1 living 0 with previous uterine rupture after medical induction of labor with stillbirth 4 years ago. She underwent emergency laparotomy with the repair. The patient spontaneously conceived and had close antenatal care throughout the pregnancy. The patient was admitted at 34 weeks of gestation and kept under close surveillance. Corticosteroid was administered. She underwent spontaneous labor at 37 weeks of gestation and emergency cesarean section was planned, delivered via a breech presentation to a live baby of 2.4 kg, APGAR score of 8/10, 9/10 at 1 and 5 minutes.

Reproductive Outcomes following Use of Barbed Suture during Laparoscopic Myomectomy

STUDY OBJECTIVE

To review pregnancy outcomes after laparoscopic myomectomy with the use of barbed suture.

DESIGN

Retrospective cohort study and follow-up survey.

SETTING

Single, large academic medical center.

PATIENTS

Patients who underwent laparoscopic myomectomy with the use of barbed suture for myometrial closure between 2008 and 2016.

INTERVENTION

Laparoscopic myomectomy and a follow-up survey regarding pregnancy outcome.

MEASUREMENTS AND MAIN RESULTS

A total of 486 patients met inclusion criteria and underwent a laparoscopic myomectomy between 2008 and 2016. Of the 428 with viable contact information, 240 agreed to participate (56%). Of those who responded to the survey, 101 (42%) attempted to get pregnant, and there were 4 unplanned pregnancies. There were 110 pregnancies among 76 survey respondents. In total, of the women attempting a postoperative pregnancy, 71% had at least 1 pregnancy. Comparing the women who did and did not conceive postoperatively, the group who got pregnant was on average younger, 33.8 ± 4.5 years vs 37.5 ± 6.5 years (p = .001); had fewer myomas removed, median = 2 (range 1-9) vs median = 2 (range 1-16) myomas (p = .038); and had a longer follow-up period, 30 months ( vs 30 (11-93 months) ± 20 (p <.001). The mean time to first postoperative pregnancy was 18.0 months (range 2-72 months). Of the 110 reported postoperative pregnancies, there were 60 live births (55%), 90% by means of cesarean section. The mean gestational age at birth was 37.8 weeks. In the cohort, there were 8 preterm births, 3 cases of abnormal placentation, 2 cases of fetal growth restriction, 3 cases of hypertensive disorders of pregnancy, and 2 cases of myoma degeneration requiring hospitalization for pain control. There were no uterine ruptures reported.

CONCLUSION

According to our findings, pregnancy outcomes after laparoscopic myomectomy with barbed suture are comparable with available literature on pregnancy outcomes with conventional smooth suture.

Uterine rupture and the risk for offspring long-term respiratory morbidity

Introduction: Uterine rupture during labor is a life-threatening event associated with high morbidity for both mother and fetus. While the immediate maternal and neonatal outcomes of uterine rupture are well established, less is known regarding the long-term respiratory morbidity of offspring which survived uterine rupture.Aim: To assess whether a history of uterine rupture at birth, is associated with an increased risk for future offspring respiratory morbidity.Materials and methods: In this population-based retrospective cohort study, all singleton deliveries between 1991 and 2014 were included. Known offspring chromosomal or congenital anomalies and cases of perinatal mortality were excluded from the analysis. The incidence of hospitalizations with respiratory morbidities, predefined in a set of ICD-9 codes, was compared between offspring delivered with or without uterine rupture. Cox proportional hazards models were conducted, to control for each confounder separately.Results: During the study period 238,622 deliveries met the inclusion criteria, of those 127 (0.053%) were complicated by uterine rupture. Rates of respiratory related hospitalizations were 7.1 and 4.9%, among offspring delivered with or without uterine rupture, respectively (p = .22), and in the Kaplan- Meier survival curves, no significant differences were found between the groups (log rank test p = .241). While using Cox proportional hazards models and controlling for each confounder separately, uterine rupture was not found to be an independent risk factor for long-term respiratory morbidity of the offspring.Conclusion: Uterine rupture was not found as an independent risk factor for offspring long-term respiratory morbidity. The limited number of cases in the exposed group, could only demonstrate a trend with no significance, and therefore further investigation is required.

Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: a retrospective review of 4396 women in East and Central Africa

OBJECTIVE

To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

DESIGN

Retrospective record review.

SETTING

Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

POPULATION

A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

METHODS

Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

MAIN OUTCOME MEASURES

Mode of delivery, stillbirth.

RESULTS

Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

CONCLUSIONS

In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.

TWEETABLE ABSTRACT

Caesarean section is increasingly performed in African women with stillbirth treated for obstetric fistula.

The Failure Rate, Related Factors, and Neonate Complications of Vaginal Delivery after Cesarean Section

Background

The rate of Cesarean Section (CS) is high in Iran. A successful Vaginal Birth After Cesarean (VBAC) section can protect mothers against the risk of having multiple CS. This study aimed to evaluate the success rate of VBAC, related factors, and the causes of failure.

Materials and Methods

This cross-sectional study was conducted on 150 pregnant women who were candidates for VBAC and admitted at maternity hospitals in Qom from 2016 to 2018. The required data were collected from the patients' records and entered into the checklist. Then, the success rate of VBAC was estimated, and related factors together with the causes of failure were determined by t-test, Chi-square, and independent-samples t-tests in SPSS v. 18 software.

Results

The mean (SD) maternal age was 32 (5.20) years and ranged from 21 to 45 years old. The success rate of VBAC was estimated to be 85.33%, and 14.67% of the patients had to repeat a CS after failure in vaginal delivery. The mean time between previous CS and present delivery was statistically significant between successful and failure groups (t ₁₂₅ = 2.32, p = 0.002). The results also revealed that the most important causes of VBAC failure were prolonged labor [odds ratio (OR) = 4.70)], full arrest (OR = 2.70), and decline fetal heart (OR = 5.31).

Conclusions

The success rate of VBAC in our study was high. However, VBAC was more successful when the interval between inter-deliveries was long, and lower complications were reported when the interval was 2-4 years.

Atypical presentation of hemorrhagic shock in pregnancy: a case highlighting the developing field of emergency medicine in Israel

BACKGROUND

Occult hemorrhagic shock secondary to uterine rupture represents a true obstetric emergency and can result in significant morbidity and mortality for both the patient and the fetus. Multiparity and prior cesarean sections are known risk factors. Typically, these patients present late in gestation, often secondary to the physiologic stresses on the uterus related to contractions. This pathology is less common earlier in pregnancy and can often be overlooked in the acute setting.

CASE PRESENTATION

We present the case of a 31-year-old female with three prior gestations, two parities and two prior cesarean sections, resulting in three live births, who presented to the Emergency Department (ED) 22-weeks pregnant with acute onset dyspnea and an episode of syncope. Due to her altered mental status there was concern for occult shock, despite normal vital signs. Large amounts of free fluid in the abdomen were noted on bedside ultrasonography with a high suspicion for uterine pathology. She was resuscitated with blood and taken immediately to the operating room for surgical management where she was found to have had a uterine rupture.

CONCLUSION

This case highlights a rare presentation of a well-known obstetric emergency, due to the patient's development of uterine rupture early in gestation. Consequently, emergency physicians should consider atraumatic hypovolemic shock, secondary to this obstetric catastrophe, even at a stage that far precedes its expected presentation. In addition, we make note of how this case validated our department's integrated emergency medicine model, the first in the State of Israel.

Influence of interpregnancy interval on uterine rupture

OBJECTIVE

This study aims to assess the independent influence of interpregnancy interval (IPI) on uterine rupture using a population-based cohort of all Ohio births, regardless of prior cesarean (PCS) or trial of labor (TOL) status.

STUDY DESIGN

Population-based retrospective cohort study of all live births in Ohio (2006-2012). Frequency of uterine rupture was quantified and stratified by number of prior cesarean deliveries and IPI. The relative and adjusted risk of IPI on uterine rupture was calculated using multivariate logistic regression.

RESULTS

Of 1,034,522 live births recorded during the 7-year study period, 249 cases of uterine rupture were identified for analysis. Two-thirds of uterine rupture cases (n = 158) occurred in women with one or more PCS and one-third (n = 91) had no prior cesarean. IPI 24-59 months had the lowest frequency of uterine rupture and was used as the referent group. IPI 12-23 and IPI ≥ 60 months were not significantly associated with risk of uterine rupture, p = .847, .540 respectively. In women with PCS, IPI < 12 months was associated with greater than two-fold increased risk of uterine rupture (aRR 2.4, CI 1.5-3.8). No association between IPI < 12 months and uterine rupture was observed in women with no PCS, p = .696.

CONCLUSION

IPI < 12 months is independently associated with uterine rupture in women with prior cesarean, but does not appear to influence risk in women with an unscarred uterus.

The Mode of delivery of grand multiparous with post-cesarean single uterine scar in low resources settings: A retrospective cohort study

The prevalence of post-caesarean scar uterus, the most important risk factor of uterine rupture is increasing globally. Grand multiparity can also increase the risk of uterine rupture. The issue of grand multiparous with single post caesarean scar is poorly investigated.

OBJECTIVES

The purpose of this study was to assess the factors associated with the mode of delivery of grand multiparous with post caesarean single uterine scar in low resources settings.

PATIENTS AND METHOD

It was a retrospective cohort study conducted from the 1st January to the 31st of May 2016, in three university teaching hospitals of the university of Yaoundé I in Cameroon. Grand multiparous (GMP) defined as parity ≥5 with single post-caesarean lower segment uterine scar admitted at a gestational age of 37 completed weeks and above were compared to grand multiparous without scar uterus at term. GMP with unknown scar were excluded. The mode of delivery and materno-fetal and neonatal outcome were investigated.

RESULTS

We included 33 GMP with single lower segment uterine scar and 120 GMP without uterine scar. Induction of labor and acute fetal distress were not related to having a scar or not in grand GMP, but augmentation of labor was less likely to be conducted in case of GMP with scar uterus(p = 0.08). The frequency of vaginal delivery was 75.8 and 87.5% in grand multiparous with and without uterine scar respectively (OR 0.17-1.16; P = 0.085), with one case of instrumental delivery in scarless group. However, single scar multiparity status increased by 2.42 folds the risk of delivery by caesarian section (P = 0.066). Cephalo-pelvic disproportion increased the indication of caesarian section by 12-fold in the GMP with scar group (p = 0.031), but mechanical dystocia related indications (CPD, macrosomia,) were present in only 4 cases out of 8 caesarian sections in the exposed group. The Apgar score at the fifth minute was better in the GMP with scar group. (p = 0.037).

CONCLUSION

Grand multiparous with single post-cesarean uterine scar should be given a chance of vaginal delivery in the absence added feto-maternal morbidity.

Imaging findings of cesarean delivery complications: cesarean scar disease and much more

In the last years, there has been a significant increase in the number of cesarean deliveries and, with it, of the number of complications following the procedure. They can be divided into early and late ones. We will illustrate herein the most common complications following cesarean section to help radiologists to recognize them. To familiarize with these various pathologic conditions is crucial to alert referring clinicians for a prompt and appropriate maternal and fetal management. Special attention will be given to the cesarean scar defect (CSD), the most common but also the most unknown of such conditions. Although often asymptomatic, a severe CSD represents a predisposing factor for subsequent complications especially in future pregnancies.

Pregnancy outcomes of women with previous caesarean sections: Secondary analysis of World Health Organization Multicountry Survey on Maternal and Newborn Health

Secondary analysis of World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) was undertaken among 173,124 multiparous women to assess the association between previous caesarean sections (CS) and pregnancy outcomes. Maternal outcomes included maternal near miss (MNM), maternal death (MD), severe maternal outcomes (SMO), abnormal placentation, and uterine rupture. Neonatal outcomes were stillbirth, early neonatal death, perinatal death, neonatal near miss (NNM), neonatal intensive care unit (NICU) admission, and preterm birth. Previous CS was associated with increased risks of uterine rupture (adjusted Odds Ratio (aOR); 7.74; 95% confidence interval (CI) 5.48, 10.92); morbidly adherent placenta (aOR 2.60; 95% CI 1.98, 3.40), MNM (aOR 1.91; 95% CI 1.59, 2.28), SMO (aOR 1.80; 95% CI 1.52, 2.13), placenta previa (aOR 1.76; 95% CI 1.49, 2.07). For neonatal outcomes, previous CS was associated with increased risks of NICU admission (aOR 1.31; 95% CI 1.23, 1.39), neonatal near miss (aOR 1.19; 95% CI 1.12, 1.26), preterm birth (aOR 1.07; 95% CI 1.01, 1.14), and decreased risk of macerated stillbirth (aOR 0.80; 95% CI 0.67, 0.95). Previous CS was associated with serious morbidity in future pregnancies. However, these findings should be cautiously interpreted due to lacking data on indications of previous CS.