| |
REPAIR OF RUPTURED UTERUS
| 1 |
Give
a single dose of prophylactic antibiotics (ampicillin
2 g IV or cefazolin 1 g IV). |
| 2 |
Open
the abdomen:
| • |
Make
a midline vertical incision below the umbilicus
to the pubic hair, through the skin and to the level
of the fascia |
| • |
Make
a 2–3 cm vertical incision in the fascia |
| • |
Hold
the fascial edge with forceps and lengthen the
incision up and down using scissors |
| • |
Use
fingers or scissors to separate the rectus muscles
(abdominal wall muscles) |
| • |
Use
fingers to make an opening in the peritoneum near
the umbilicus. Use scissors to lengthen the incision
up and down in order to see the entire uterus.
Carefully, to prevent bladder injury, use scissors
to separate layers and open the lower part of the
peritoneum |
| • |
Examine
the abdomen and the uterus for site of rupture
and remove clots |
| • |
Place
a bladder retractor over the pubic bone and place
self-retaining abdominal retractors. |
|
| 3 |
Deliver
the baby and placenta. |
| 4 |
Infuse
oxytocin 20 units in 1 L IV fluids (normal saline or
Ringer’s lactate) at 60 drops per minute until
the uterus contracts and then reduce to 20 drops per minute. |
| 5 |
Lift
the uterus out of the pelvis in order to note the extent
of the injury. |
| 6 |
Examine
both the front and the back of the uterus. |
| 7 |
Hold
the bleeding edges of the uterus with Green Armytage
clamps (or ring forceps). |
| 8 |
Separate
the bladder from the lower uterine segment by sharp or
blunt dissection. If the bladder is scarred to the uterus,
use fine scissors. |
Repairing the uterine tear
| 1 |
Repair
the tear with a continuous locking stitch of 0 non absorbable
(or polyglycolic) suture. If the bleeding points are
deep, use figure-of-8 sutures. If bleeding is not controlled
or if the rupture is through a previous classical or vertical
incision, place a second layer of suture. |
| 2 |
Ensure
that the ureter is identified and exposed to avoid including
it in a stitch.
|
| 3 |
If
the woman has requested tubal ligation, perform the procedure
at this time. |
| 4 |
If
the rupture is too extensive for repair, proceed with
hysterectomy. Control bleeding by clamping with long
artery forceps and ligating. |
Rupture through cervix and vagina
| 1 |
If
the uterus is torn through the cervix and vagina, mobilize
the bladder at least 2 cm below the tear. |
| 2 |
If
possible, place a suture 1 cm below the upper end of
the cervical tear and keep traction on the suture to
bring the lower end of the tear into view as the repair
continues.
|
Rupture laterally through uterine
artery
| 1 |
If
the rupture extends laterally to damage one or both uterine
arteries, ligate the injured artery. |
| 2 |
Identify
the arteries and ureter before ligating the uterine vessels.
|
Rupture
with broad ligament haematoma
| 1 |
If
the rupture has created a broad ligament haematoma, clamp,
cut and
tie off the round ligament.
|
| 2 |
Open
the anterior leaf of the broad ligament and drain off
the haematoma.
|
| 3 |
Inspect
the area carefully for injury to the uterine artery or
its branches.
Ligate any bleeding vessels. |
Repair of bladder injury
| 1 |
Identify
the extent of the injury by grasping each edge of the
tear with a clamp and gently stretching. Determine if
the injury is close to the bladder trigone (ureters and
urethra).
|
| 2 |
Dissect
the bladder off the lower uterine segment with fine scissors
or with a sponge on a clamp.
|
| 3 |
Free
a 2 cm circle of bladder tissue around the tear. |
| 4 |
Repair
the tear in two layers with continuous 3-0 chromic non
absorbable (or polyglycolic) suture:
| • |
Suture
the bladder mucosa (thin inner layer) and bladder
muscle (outer
layer) |
| • |
Invert
(fold) the outer layer over the first layer of
suture and place
another layer of suture |
| • |
Ensure
that sutures do not enter the trigone area. |
|
| 5 |
Test
the repair for leaks:
| • |
Fill
the bladder with sterile saline or water through
the catheter |
| • |
If
leaks are present, remove the suture, repair and
test again. |
|
| 6 |
If
it is not certain that the repair is well away from the
ureters and urethra, complete the repair and refer the
woman to a higher-level facility for an intravenous urogram. |
| 7 |
Keep
the bladder catheter in place for at least 7 days and
until urine is clear. Continue IV fluids to ensure flushing
of the bladder. |
Post-procedure care
| 1 |
If
there are signs of infection or the woman currently has
fever, give a combination of antibiotics until she is
fever-free for 48 hours:
| • |
Ampicillin
2 g IV every 6 hours plus gentamicin 5 mg/kg body
weight IV every 24 hours plus metronidazole 500
mg IV every 8 hours. |
|
| 2 |
Give
appropriate analgesic drugs.
|
| 3 |
If
there are no signs of infection, remove the abdominal
drain after 48 hours. |
| 4 |
If
tubal ligation was not performed, offer family planning.
|
If the woman wishes to have more children, advise her to have elective
caesarean section for future pregnancies. Because there is
an increased risk of rupture with subsequent pregnancies, the
option of permanent contraception needs to be discussed with
the woman after the emergency is over.
|
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