Case 78: Labour

 CASE 78: LABOUR

History

A 31-year-old woman is admitted with contractions at 40 weeks’ gestation. This is her fourth

pregnancy, having had two terminations approximately 10 years ago and an elective caesarean section for breech presentation 3 years ago.

During this pregnancy she has had an amniocentesis because of a high estimated risk for

Down’s syndrome at 11–14-week scan. However a normal karyotype was found and subsequent fetal echocardiography was normal. In view of her previous caesarean section she was

seen by the obstetric consultant in the antenatal clinic at 28 weeks to discuss mode of delivery. After counselling, a plan was agreed for a vaginal delivery.

She was admitted with spontaneous rupture of membranes after which she had begun to

contract irregularly. The contractions became stronger and more regular over the next 2 h

after admission and she requested an epidural. Vaginal examination was performed and the

cervix was found to be 4 cm dilated. The head was in the occipitotransverse position, 1 cm

above the level of the ischial spines. There was a small amount of caput and moulding.

An epidural was sited and an indwelling urinary catheter inserted. Three hours later the

woman reported more severe pain which did not disappear between contractions. At that

time approximately 200 mL of fresh blood was seen coming from the vagina.

Examination

The heart rate is 105/min and blood pressure 105/58 mmHg. The woman feels warm and well

perfused. The abdomen is soft and the uterus is also soft but very tender, with easy palpation

of fetal parts. On vaginal examination the cervix is 6 cm dilated and the fetal head feels high

in the pelvis and poorly applied to the cervix. The catheter contains blood-stained urine.

INVESTIGATIONS

The cardiotocograph (CTG) is described below and shown in Fig. 78.1.

CTG report:

Fetal heart rate initially 150/min with variability 20/min

Sudden prolonged fall in fetal heart rate to 80/min

No accelerations

Loss of uterine activity at time of fetal bradycardia100 Cases in Obstetrics and Gynaecology

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Questions

• What is the likely diagnosis?

• How would you manage this patient?

• What are the possible further complications for this patient?

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Figure 78.1 Cardiotocograph.Case 78: Labour

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ANSWER 78

The CTG shows that the contractions have stopped. This can be due to the pressure transducer losing contact with the patient, but in this case the combination of other factors and

the fact that the uterus is soft on palpation suggests that the contractions really have suddenly stopped.

The diagnosis is of uterine rupture. The constant pain, vaginal bleeding, sudden loss of contractions, change in CTG, easy palpation of fetal parts and haematuria are all classic features.

Uterine rupture is thought to occur in up to 1 in 200 labours following caesarean section. It

is more common when labour is induced with prostaglandins or augmented with oxytocin

infusion, but may occur even in an apparently ‘normal’ labour such as this. Uterine rupture

may very rarely occur in women without previous caesarean section, either because of previous surgery such as myomectomy, with trauma, or spontaneously. The major risk factor for

uterine rupture is previous caesarean section.

General resuscitation measures should be commenced immediately:

• large-bore intravenous access

• full blood count, coagulation test

• 6-unit crossmatch requested

• intravenous fluids.

The emergency theatre team, senior obstetrician and paediatrician should be summoned and

the woman transferred to theatre immediately for laparotomy, which may need to be under general anaesthetic as the epidural is unlikely to be adequate for laparotomy within a few minutes.

At laparotomy, the fetus should be delivered from the abdomen and the placenta removed. It

may be possible to repair the uterine defect. However if bleeding is substantial then other measures may need to be employed such as a B-Lynch haemostatic suture or even hysterectomy.

If the uterus is preserved, then any future pregnancies should be very closely monitored with

elective delivery by caesarean section at 37 weeks’ gestation.

! Complications of uterine rupture

• Fetal:

• death

• cerebral palsy from hypoxic brain injury

• Maternal:

• postpartum haemorrhage

• hysterectomy

• coagulopathy

KEY POINTS

• Dehiscence of a previous caesarean section scar can range from a dramatic to

subtle presentation.

• Change in CTG pattern, persistent abdominal pain, cessation of contractions,

maternal tachycardia or haematuria should alert the clinician to the possibility of

rupture.