Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study

doi:10.1136/bmj.38160.634352.55

BMJ 2004;329:375 (14 August), doi:10.1136/bmj.38160.634352.55 (published 19 July 2004)

Paper

Factors predisposing to perinatal death related to uterine rupture during attempted vaginal birth after caesarean section: retrospective cohort study

Gordon C S Smith, professor¹, Jill P Pell, consultant², Dharmintra Pasupathy, specialist registrar³, Richard Dobbie, senior statistician⁴

¹ Department of Obstetrics and Gynaecology, Cambridge University, Cambridge CB2 2QQ, ² Department of Public Health, Greater Glasgow NHS Board, Glasgow G3 8YU, ³ Departments of Obstetrics and Gynaecology, Addenbrooke's NHS Trust, Cambridge CB2 2SW, ⁴ Information and Statistics Division, Common Services Agency, Edinburgh EH5 3SE

Correspondence to: G C S Smith gcss2{at}cam.ac.uk

Objective To determine the factors associated with an increasedrisk of perinatal death related to uterine rupture during attemptedvaginal birth after caesarean section.

Design Population based retrospective cohort study.

Setting Data from the linked Scottish Morbidity Record and Stillbirthand Infant Death Survey of births in Scotland, 1985-98.

Participants All women with one previous caesarean deliverywho gave birth to a singleton infant at term by a means otherthan planned repeat caesarean section (n = 35 854).

Main outcome measures All intrapartum uterine rupture and uterinerupture resulting in perinatal death (that is, death of thefetus or neonate).

Results The overall proportion of vaginal births was 74.2% andof uterine rupture was 0.35%. The risk of intrapartum uterinerupture was higher among women who had not previously givenbirth vaginally (adjusted odds ratio 2.5, 95% confidence interval1.6 to 3.9, P < 0.001) and those whose labour was inducedwith prostaglandin (2.9, 2.0 to 4.3, P < 0.001). Both factorswere also associated with an increased risk of perinatal deathdue to uterine rupture. Delivery in a hospital with < 3000births a year did not increase the overall risk of uterine rupture(1.1, 0.8 to 1.5, P = 0.67). However, the risk of perinataldeath due to uterine rupture was significantly higher in hospitalswith < 3000 births a year (one per 1300 births) than in hospitalswith $≥$ 3000 births a year (one per 4700; 3.4, 1.0 to 14.3, P= 0.04).

Conclusion Women who have not previously given birth vaginallyand those whose labour is induced with prostaglandin are atincreased risk of uterine rupture when attempting vaginal birthafter caesarean section. The risk of consequent death of theinfant is higher in units with lower annual numbers of births.

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