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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 2 - Symptoms


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 

  • Vertical scars from a previous caesarean section may rupture before labour or during the latent phase. 

  • Transverse scars typically rupture during active labour or during the expulsive phase.

  • The rupture may extend only a short distance into the myometrium with little pain or bleeding. The fetus and placenta may remain in the uterus and the fetus may survive for minutes or hours.

 

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.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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