Rupture of the uterus: a review of 32 cases in a general hospital in ZambiaBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7040.1204 (Published 11 May 1996) Cite this as: BMJ 1996;312:1204
- Mulumba Nkata, obstetrician-gynaecologista
- Accepted 12 January 1996
Rupture of the uterus is a major cause of maternal and perinatal deaths.1 This study aimed to identify the risk factors associated with uterine rupture and to determine maternal and fetal outcomes.
Subjects, methods, and results
Between 1 July 1993 and 30 June 1994, 32 cases of uterine rupture were recorded at Mansa General Hospital, Zambia. This 412 bed secondary care centre receives referrals from hospitals, dispensaries, and health centres within Luapula province (population 160000). During the study period there were 1858 deliveries, including 98 caesarean sections.
Table 1 shows the age and parity of women with uterine rupture. Age ranged from 15 to 46 years (mean 23 (SD 7) years), with a significantly higher proportion of teenagers than among all women giving birth (12/32 (38%) v 321/1858 (17%); χ2=8.86, df=1, P<0.01). Parity ranged from 1 to 11 (mean 2 (SD 2)). The study group contained a higher proportion of nulliparous women (14/32 (44%) v 501/1858 (27%); χ2=4.4, df=1, P<0.05) but not multiparous women (14/32 (44%) v 778/1858 (42%)) than overall.
Twenty patients with uterine rupture (63%) had not been booked for delivery in hospital. Rupture occurred during labour in 30 cases (94%). Rupture was associated with cephalopelvic disproportion in 24 cases (75%). Three women had previously had a caesarean section. Two ruptures occurring in hospital were due to oxytocic stimulation and assisted breech delivery with undiagnosed mild hydrocephalus. Postmortem examination of two patients who arrived in moribund condition showed a macerated fetus with its placenta outside the uterus in the abdominal cavity in one and a complete rupture in the lower uterine segment complicated with bladder injuries in the other.
Laparotomy (performed in 30 cases) showed complete uterine rupture in 21 patients (70%), located in the lower uterine segment in 16, and bladder injury in seven (23%). Procedures were carried out in 30 cases: subtotal hysterectomy in 14 cases (47%); caesarean section with uterine repair in eight (27%); uterine repair only in eight. Bladder injuries were repaired in five cases.
Postoperative mortality was high (14/32; 44%) and mainly due to sepsis (11 patients; 79%). Higher mortality was associated with nulliparity (79%), teen age (71%); and anaemia, sepsis, and shock on admission (64%). Sepsis and maternal mortality increased with time since the rupture and the distance between hospital and the patient's home or referring centre. Postoperative mortality was similar for patients booked or not (5/10 (50%) v 11/20 (55%)). One late complication, a vesicovaginal fistula, was due to bladder necrosis caused by prolonged fetal head compression before operation.
Mortality did not differ significantly in patients who underwent hysterectomy and those treated by uterine repair (5/14 (36%) v 11/16 (69%); χ2=3.28, df=1, P>0.05). Fetal mortality was 100%.
Because of inaccessibility of essential health information, lack of transportation, poor access to fixed health care services, and shortcomings in the supervision and monitoring of home deliveries, uterine rupture is common in rural and illiterate women.2 3 Those most affected are primigravid teenagers living far from hospital and relying on a traditional birth attendant who is unable to diagnose cephalopelvic disproportion.
When labour is prolonged and delivery delayed, herbal preparations with oxytocic and analgesic components are given orally by traditional birth attendants or inserted into the vagina, leading to uterine hypertonia, ruptured uterus, and fetal death.4 This is less frequent in multiparous women, where cephalopelvic disproportion is rare and labour proceeds quite quickly. Mortality was similar in booked and unbooked patients because many women attempted to deliver at home with traditional midwives, whose hazardous practices can lead to uterine rupture, sepsis, and shock.
The health education of rural people, the training and supervision of traditional birth attendants, and availability of transport may reduce the incidence of uterine rupture in remote areas. Particular attention to regulation of training and practices of traditional birth attendants is required. Maternal prognosis may improve if women marry later and if family planning and antenatal and delivery care are available near women's homes and are affordable.
Conflict of interest None.