Uterine rupture with attempted vaginal birth after cesarean delivery: Decision-t

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Citation(s):

Holmgren C et al. Uterine rupture with attempted vaginal birth after cesarean delivery: Decision-to-delivery time and neonatal outcome. Obstet Gynecol 2012 Apr; 119:725.

How Fast Is Fast Enough? Decision-to-Delivery Time in Uterine Rupture

Better neonatal outcomes resulted when cesarean delivery occurred within 18 minutes of suspected uterine rupture.

Uterine rupture, the most feared complication of a trial of labor after cesarean (TOLAC), is a rare, but occasionally catastrophic, event. Guidelines of the American College of Obstetricians and Gynecologists recommend that TOLAC be undertaken "in facilities with staff immediately available to provide emergency care," but no precise definition of "immediately" is provided (JW Womens Health Aug 5 2010). To determine the effect of time to delivery on neonatal outcomes, investigators conducted a retrospective study of all cases of uterine rupture at 10 institutions in Utah.

From 2000 through 2009, 36 cases of overt uterine rupture occurred in 11,000 attempted TOLAC deliveries. An adverse fetal outcome (defined as umbilical artery pH <7.0 or a 5-minute Apgar score 7) occurred in 13 of these cases. Median time between recognition of uterine rupture (defined as the moment immediate cesarean delivery was ordered or an abnormal fetal heart rate was documented) and delivery was 19 minutes (range, 9–40 minutes) among deliveries with an adverse outcome and 14 minutes (range, 0–38 minutes) in those without. Outcomes were best when decision-to-delivery interval was <18 minutes.

Comment: This study is limited by its retrospective nature and by the decision to start the clock at events that might not reflect the true time of uterine rupture. Potential confounding factors, such as differences in the "safety culture" of obstetric teams or institutions, are not captured in this study, although type of hospital (community, tertiary, or university) had no significant effect. Avoidance of trial of labor after cesarean has resulted in a marked increase in cesarean deliveries in the U.S. Although the findings of this study are not compelling enough to restrict hospitals from offering TOLAC, they do provide benchmarks for obstetric personnel to consider when establishing quality and safety standards.

— , MD, MPH

http://womens-health.jwatch.org/cgi/content/full/2012/405/1?q=etoc_jwwomen

Gail Neuman RNC BSN CPHW, Notary Publiccertified in high risk OBchildbirth/lactation educator & student nurse practitionerNRP, AHA BLS for Healthcare & Heartsaver Family/Friends instructor Perinatal Nurse Associates801 N. Tustin Ave., Suite 305Santa Ana, CA 92705Life is not about waiting for the storm to pass...It's about learning to dance in the rain.--Unknown