Uterine Rupture and Hypoxic Ischemic Encephalopathy (HIE)
During pregnancy, labor and delivery, there are typically no tears in the uterus. In certain circumstances, however, the uterus can rupture throughout some or all of its layers, compromising the fetus’ oxygen supply and jeopardizing the mother’s health. Uterine rupture often leads to severe bleeding, and the baby may even move into the mother’s abdomen when it is time to deliver. Uterine rupture typically happens during a vaginal birth after cesarean section (VBAC) when scars from previous C-sections or uterine or abdominal surgeries tear during labor, though, in 18 percent of cases it occurs when the uterus is unscarred.
A ruptured uterus is an extremely dangerous complication that can occur during pregnancy. If the uterus ruptures, the baby can become severely deprived of oxygen (birth asphyxia) and develop a brain injury called hypoxic ischemic encephalopathy (HIE), which can cause seizures, cerebral palsy, intellectual disabilities and developmental delays. If a uterine rupture occurs when the baby is premature, the birth asphyxia may cause periventricular leukomalacia (PVL), which is a brain injury characterized by death and damage of the brain’s white matter, especially near the ventricles. In PVL, fluid filled cysts may be left behind when the white matter dies. Although more common in premature babies, PVL can occur in term babies after an insult to the brain. Like hypoxic ischemic encephalopathy (HIE), periventricular leukomalacia can also cause seizures, cerebral palsy and developmental delays.
How a Ruptured Uterus Can Cause Birth Asphyxia and Hypoxic Ischemic Encephalopathy (HIE)
The uterus (womb) encircles the baby and the amniotic fluid. The placenta is attached to the inside of the womb and the umbilical cord arises from the placenta. The baby receives all her oxygen through blood that travels from the mother through vessels the run through the uterus and placenta, and then to the baby through the umbilical cord. The path of oxygen-rich blood is as follows: uterine vessels à placental vessels à umbilical vein à baby. Certain vessels of the uterus and placenta are part of what’s termed the uteroplacental circulation, and this circulation brings the blood to the umbilical vein.
A uterine rupture is a complete tear through all uterine layers, and it typically occurs when there is scarring from surgeries, such as a previous C-section delivery or uterine or abdominal surgeries. A ruptured uterus creates numerous problems that can cause the baby to experience birth asphyxia. The location and extent of the tear and the baby’s reserves play a role in how severe the birth asphyxia will be. The baby may also end up outside the womb and in the mother’s abdomen when a rupture occurs. Regardless of the extent of the rupture, the baby must be delivered by emergency C-section as soon as a ruptured uterus occurs in order to prevent a lack of oxygen to the baby’s brain and birth asphyxia.
A ruptured uterus can cause the baby to experience birth asphyxia by the following mechanisms:
- The tear causes the mother to lose so much blood that she is unable to deliver adequate oxygen-rich blood to the baby. The mother may even have such a severe hemorrhage that she goes into shock (blood pressure is severely low), which is life-threatening for the mother and baby.
- The rupture is at or very close to the placenta and it severs vessels involved in uteroplacental circulation, thereby severely reducing the amount of blood going to the baby.
- The rupture affects the placenta. Placental abruption and uterine rupture can occur together. One study found that 18% of uterine ruptures occurred when placental abruption was present and the uterus was unscarred.
- If the baby starts to move into the mother’s abdomen when the uterus is ruptured, many serious medical complications can occur, such as the umbilical cord becoming stretched, compressed or torn.
Risk Factors for Uterine Rupture
A scarred uterus is the biggest risk factor for a ruptured uterus. The types of scars that can cause a uterine rupture include the following:
- Scar from a C-section
- Hysterotomy scar. Hysterotomy is in incision in the uterus made during a C-section when the baby has shoulder dystocia (shoulder caught on mother’s pelvis).
- Uterine perforation scar. This can occur as a result of any complication involving the uterus and trans-cervical procedures.
- Myomectomy or metroplasty scar. These scars are from the removal of fibroids in the uterus.
- Scar from the previous repair of a ruptured uterus.
During pregnancy, imaging of scars should be performed. An intact, thick scar means the repair of the previous C-section or any other uterine surgery was likely pretty good. A thin scar or defect should cause the physician to worry about a possible uterine rupture during labor as well as during pregnancy.
Most uterine ruptures occur because a scar from a previous C-section is present. Some of these involve classical C-section scars, which are longitudinal (across the abdomen), upper segment scars. These scars can not only rupture during labor and delivery, but they can rupture during pregnancy as well. Rupture of lower segment C-section scars usually takes place during labor.
If the uterus has no scarring, the occurrence of a uterine rupture is estimated to be less than 1%. Rupture in an unscarred uterus has been attributed to weakness in the middle layer of the uterine wall (which functions to induce contractions), disorders of the collagen matrix, and abnormal architecture of the uterine cavity. Overdistention of the uterine cavity (e.g., carrying a large baby or multiple babies) is the major physical factor in these cases of rupture. Labor that takes longer than expected due to slow cervical dilation can place prolonged stress on the uterine wall, with eventual loss of the wall’s integrity.
Other risk factors for uterine rupture include the following:
- Cephalopelvic disproportion (CPD). This is when the mother’s pelvis is too small for the size of the baby, resulting in the baby being unable to pass through the birth canal.
- Malpresentation. This is when the baby is not in the normal head-first position. Malpresentations include brow, face, breech and shoulder presentations.
- Grand multiparity. This is when the mother has given birth 5 or more times.
- Uncontrolled use of Pitocin (oxytocin), Cytotec or other labor induction drugs. This is probably the leading cause of rupture of the unscarred uterus. Pitocin can cause contractions to be too strong and too frequent, which puts a lot of strain on the uterus. A recent study found that in one medical center, Pitocin had been administered in 77% of their uterine rupture cases. The chance of Pitocin-induced rupture increases with women who have had previous traumatic births.
- Placental abruption. This is when the placental lining separates from the uterus. This can cause the baby to be either partially or completely cut off from the mother’s circulation.
- Multiple fetuses (twins, triplets, etc.)
- Post-term labor
- Operative deliveries. Using a delivery device, such as forceps or performing internal version, can cause uterine rupture. Internal version is when the physician inserts a hand into the womb and grasps the baby by one or both feet to turn her.
- Single layer closure in prior C-section
- Macrosomia or large for dates baby (large for gestational age, or LGA)
- Multiple fetuses (twins, triplets, etc.)
- Fetal malposition (e.g., breech presentation)
- Maternal obesity
- History of failure to tolerate labor with fetal distress
- Labor dystocia (difficult labor), particularly at advanced gestation
- Low Bishop score on admission to the labor and delivery unit (used to assess the likelihood of achieving a successful labor induction)
- Previous uterine rupture
- Certain obstetrical maneuvers, such as internal version (physician’s adjustment of the baby’s position in the womb by placing one hand in the mother’s vagina and the other on her abdomen) and extraction of a baby in breech presentation and use of vacuum extractors and forceps
- African American race
- Trauma (gunshot wound, car accident)
When Pitocin is used in the presence of other risk factors for uterine rupture, such as grand multiparity, malpresentation, or a previous C-section scar, it is extremely dangerous. In fact, using Pitocin when these conditions are present is contraindicated.
Experts emphasize that the best way to prevent uterine rupture is through prophylaxis; physicians must be aware of the mother’s past medical history and must closely watch her during pregnancy and labor. Great effort must be made in diagnosing even minor degrees of CPD or malpresentation, and in treating grand multiparity and other risk factors, especially placental abruption. Mothers with risk factors should be attended to and treated in a special high-risk intensive care zone in the labor department by specially trained physicians and personnel. Difficult operative deliveries should not be attempted, and instead, delivery by C-section should take place.
A vaginal birth after C-section (VBAC) should be attempted only on a mother who has had a previous transverse, lower-uterine segment C-section for a non-recurring condition, and only after a very careful assessment has been made by the physicians with a determination that vaginal delivery would be favorable. Informed consent from the mother is crucial, and this involves discussing all the risks of a VBAC as well as the alternatives, such as a C-section delivery.
Signs and Symptoms of Uterine Rupture
It is critical for the medical team to closely monitor a mother and baby during labor and delivery – and throughout pregnancy – so that prompt treatment of dangerous conditions such as uterine rupture can occur.
Signs and symptoms of a ruptured uterus include the following:
- Non-reassuring heart tracings, fetal heart rate decelerations
- Vaginal bleeding or hemorrhaging
- Sudden abdominal pain
- Loss of uterine contractions
- Baby recedes back into the birth canal
- Hemodynamic instability (blood pressure and heart rate problems)
The classic signs of uterine rupture have been shown to be unreliable and sometimes nonexistent. Thus, non-reassuring fetal heart tones on the heart monitor are the most common and often the only signs of uterine rupture. In most cases, signs of fetal distress will appear before pain or bleeding. It therefore is critical that physicians pay close attention to the fetal heart monitor and be prepared to perform an emergency C-section. When uterine rupture is present, a prompt delivery by emergency C-section delivery must occur in order to avoid birth asphyxia, hypoxic ischemic encephalopathy (HIE) and lifelong problems, such as seizures, cerebral palsy, and developmental disabilities.
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Birth Injury Video: Birth Injury Attorneys Discuss Uterine Rupture, HIE (Birth Asphyxia) and Birth Injuries
Watch a video of Uterine Rupture attorneys Jesse Reiter Rebecca Walsh discussing birth asphyxia and how this can cause severe birth injuries.
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