Tag: dr erik erichsen

Ultimate result of unrelieved obstructive labor

Symptoms and signs

• Shock
• Abdominal pain
• Contractions absent
• Fetal heartbeats absent
• Small parts of fetus are visible and/or palpable directly under the skin

Diagnosis

• Usually straight forward
• Occassionally challenging
  • Particularly with posterior ruptures
• Abdominal aspiration:
  • Blood at aspiration confirms the diagnosis
  • No blood at aspiration is inconclusive

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If diagnosis is still in doubt, there are two options:

I. Do a laparotomy

Rupture is present:

• Proceed with repair

No rupture is present:

• Close the abdominal incision
• Perform destructive delivery

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II. Deliver the dead fetus by destructive procedure

Check uterine cavity manually for rupture

• Rupture is present
  • Proceed with laparotomy & repair

In selected cases, when:

• Peritoneum is intact
• The palpating hand does not come into direct contact with the bowels
• Patient is critical
• Surgeon unexperienced
  • Relay on firm gauze packing
  • Remove pack in OR after 24 hours

TYPES of RUPTURES:

• Anterior  –   transverse or longitudinal  –  with or without bladder rupture
• Lateral     –   always longitudinal              –  with or without bladder rupture
• Posterior –   transverse or longitudinal –  always without bladder rupture

The far most common type is the anterior transverse.

Use the same principles as in trauma surgery:

• Minimal Surgery
• Make a fast and simple repair of the rupture
• Do not traumatize the patient further by performing hysterectomy.   
• The only indications for hysterectomy are:
  • Gangrene of the uterus
  • When technically easier and faster to do than a repair

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REPAIR OF RUPTURED UTERUS

• Main objectives of the repair are to:
  • Stop bleeding
  • Separate the abdominal cavity from vagina

SURGICAL TECHNIQUE

• Resuscitate with i.v. fluids
• Give i.v. antibiotics (ampicillin/gentamycin/metronidazole)
• Transfuse one or two units of fresh blood if available
• Ketamine i.v. works well
• General anesthesia is even better when a skilled anesthetist is present
• Repair the rupture with a continuous inverting suture
• Use heavy resorbable suture (Chromic Catgut or Polyglycolic Acid)
• Cover the repair with a second layer of peritoneum
• In critical situations suturing the torn peritoneum may be sufficient and lifesaving.
• Reaching the most distal part of a rupture may be challenging.
• Do not struggle
• Leaving the most distal part of the rupture open for drainage is in fact an advantage.
• In case the patient has no – or only one – living child
  • The relatives promise solemnly to take her to hospital for C/S at the next delivery
  • Offer that option.
  • Otherwise perform bilateral tubal ligation (BTL).
• Clean the abdominal cavity
  • Remove all contaminated, infected blood
  • Irrigate with plenty of saline before closure.

REPAIR OF ANTERIOR TRANSVERSE UTERINE RUPTURE

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REPAIR OF LATERAL UTERINE RUPTURE

• Close rupture with a continuous suture
• Leave the most distal part of the rupture open for drainage
• Cover the repair with a second layer of peritoneum

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REPAIR OF POSTERIOR LONGITUDINAL

• Same technique as for lateral rupture
• A second layer is usually not possible

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REPAIR OF POSTERIOR TRANSVERSE RUPTURE

• Somewhat challenging as the lower segment is short and inaccessible.
• Repair with interrupted inverting sutures in a row
• Tie suture when all are in place

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REPAIR OF RUPTURED BLADDER

Bloody urine raises the suspicion of bladder involvement

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SURGICAL TECHNIQUE

• Repair bladder with one or two layers of continuous inverting resorbable suture
• Watch out for the ureters
• Repair the ruptured uterus
• In critical situations the bladder can be left unrepaired with an indwellingath catheter
• The resulting VVF (vesicovaginal fistula) can be repaired later

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Using these principles resulted in the present maternal mortality of less than 3 % in Aira Hospital as seen in the presentation below. One of the two deceased patients in the material expired before reaching the operating theater. The maternal survival rate after surgery is thus 98.6 % and mortality with surgical treatment 1,4 %

An improvement from 5% mortality previous 10 years

An improvement from the 5 % mortality rate during the preceding 10 years.