Repair of ruptured uterus

• Review for indications.

• Review operative care principles and start an IV infusion.

• Give a single dose of prophylactic antibiotics:

- ampicillin 2 g IV;

- OR cefazolin 1 g IV.

• Open the abdomen:

- Make a midline vertical incision below the umbilicus to the pubic hair, through the skin and to the level of the fascia;

- Make a 2-3 cm vertical incision in the fascia;

- Hold the fascial edge with forceps and lengthen the incision up and down using scissors;

- Use fingers or scissors to separate the rectus muscles (abdominal wall muscles);

- Use fingers to make an opening in the peritoneum near the umbilicus. Use scissors to lengthen the incision up and down in order to see the entire uterus. Carefully, to prevent bladder injury, use scissors to separate layers and open the lower part of the peritoneum; 

- Examine the abdomen and the uterus for site of rupture and remove clots;

- Place a bladder retractor over the pubic bone and place self-retaining abdominal retractors.

• Deliver the baby and placenta.

• Infuse oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute until the uterus contracts and then reduce to 20 drops per minute.

• Lift the uterus out of the pelvis in order to note the extent of the injury.

• Examine both the front and the back of the uterus.

• Hold the bleeding edges of the uterus with Green Armytage clamps (or ring forceps).

• Separate the bladder from the lower uterine segment by sharp or blunt dissection. If the bladder is scarred to the uterus, use fine scissors.

RUPTURE THROUGH CERVIX AND VAGINA

• If the uterus is torn through the cervix and vagina, mobilize the bladder at least 2 cm below the tear.

• If possible, place a suture 1 cm below the upper end of the cervical tear and keep traction on the suture to bring the lower end of the tear into view as the repair continues. 

RUPTURE LATERALLY THROUGH UTERINE ARTERY

• If the rupture extends laterally to damage one or both uterine arteries, ligate the injured artery. 

• Identify the arteries and ureter prior to ligating the uterine vessels (Fig P-53).

RUPTURE WITH BROAD LIGAMENT HAEMATOMA

• If the rupture has created a broad ligament haematoma (Fig S-2), clamp, cut and tie off the round ligament.

• Open the anterior leaf of the broad ligament. 

• Drain off the haematoma manually, if necessary.

• Inspect the area carefully for injury to the uterine artery or its branches. Ligate any bleeding vessels.

REPAIRING THE UTERINE TEAR

• Repair the tear with a continuous locking stitch of 0 chromic catgut (or polyglycolic) suture. If bleeding is not controlled or if the rupture is through a previous classical or vertical incision, place a second layer of suture. 

• Ensure that the ureter is identified and exposed to avoid including it in a stitch. 

• If the woman has requested tubal ligation, perform the procedure at this time.

• If the rupture is too extensive for repair, proceed with hysterectomy.

• Control bleeding by clamping with long artery forceps and ligating. If the bleeding points are deep, use figure-of-eight sutures.

• Place an abdominal drain.

• Ensure that there is no bleeding. Remove clots using a sponge.

• In all cases, check for injury to the bladder. If a bladder injury is identified, repair the injury (see below).

• Close the fascia with continuous 0 chromic catgut (or polyglycolic) suture. 

Note: There is no need to close the bladder peritoneum or the abdominal peritoneum.

• If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 catgut (or polyglycolic) sutures. Close the skin with a delayed closure after the infection has cleared. 

• If there are no signs of infection, close the skin with vertical mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.

REPAIR OF BLADDER INJURY

• Identify the extent of the injury by grasping each edge of the tear with a clamp and gently stretching. Determine if the injury is close to the bladder trigone (ureters and urethra).

• Dissect the bladder off the lower uterine segment with fine scissors or with a sponge on a clamp.

• Free a 2 cm circle of bladder tissue around the tear.

• Repair the tear in two layers with continuous 3-0 chromic catgut (or polyglycolic) suture:

- Suture the bladder mucosa (thin inner layer) and bladder muscle (outer layer);

- Invert (fold) the outer layer over the first layer of suture and place another layer of suture;

- Ensure that sutures do not enter the trigone area.

• Test the repair for leaks:

- Fill the bladder with sterile saline or water through the catheter;

- If leaks are present, remove the suture, repair and test again. 

• If it is not certain that the repair is well away from the ureters and urethra, complete the repair and refer the woman to a higher-level facility for an intravenous pyelogram.

• Keep the bladder catheter in place for at least 7 days and until urine is clear. Continue IV fluids to ensure flushing of the bladder.

POST-PROCEDURE CARE

• Review postoperative care principles.

• If there are signs of infection or the woman currently has fever, give a combination of antibiotics until she is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours; 

- PLUS metronidazole 500 mg IV every 8 hours.

• Give appropriate analgesic drugs.

• If there are no signs of infection, remove the abdominal drain after 48 hours.

• Offer other health services, if possible.

• If tubal ligation was not performed, offer family planning (Table S-3). If the woman wishes to have more children, advise her to have elective caesarean section for future pregnancies.

Because there is an increased risk of rupture with subsequent pregnancies, the option of permanent contraception needs to be discussed with the woman after the emergency is over.

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