Labour with scarred uterus

PROBLEM

• A woman in labour has a scarred uterus from a previous uterine surgery.

GENERAL MANAGEMENT

• Start an IV infusion and infuse IV fluids.

• If possible, identify the reason for the uterine scar. Caesarean section and other uterine surgeries (e.g. repair of a previous uterine rupture, excision of an ectopic pregnancy implanted in the cornua) leave a scar in the uterine wall. This scar can weaken the uterus, leading to uterine rupture during labour (Box S-6).

BOX S-6 Rupture of uterine scars 

SPECIFIC MANAGEMENT

Studies have shown that some 50% of cases with low transverse caesarean scars can deliver vaginally. The frequency of rupture of low transverse scars during a careful trial of labour is reported as less than 1%.

TRIAL OF LABOUR

• Ensure that conditions are favourable for trial of labour, namely:

- The previous surgery was a low transverse caesarean incision;

- The fetus is in a normal vertex presentation;

- Emergency caesarean section can be carried out immediately if required.

• If these conditions are not met or if the woman has a history of two lower uterine segment caesarean sections or ruptured uterus, deliver by caesarean section.

• Monitor progress of labour using a partograph.

• If labour crosses the alert line of the partograph, diagnose the cause of slow progress and take appropriate action:

- If there is slow progress in labour due to inefficient uterine contractions (Table S-10), rupture the membranes with an amniotic hook or a Kocher clamp and augment labour with oxytocin;

- If there are signs of cephalopelvic disproportion or obstruction (Table S-10), deliver immediately by caesarean section.

• If there are signs of impending uterine rupture (rapid maternal pulse, persistent abdominal pain and suprapubic tenderness, fetal distress), deliver immediately by caesarean section.

• If uterine rupture is suspected, deliver immediately by caesarean section and repair the uterus  or perform hysterectomy.

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