Uterine Rupture in Labour: A Continuing Obstetric Challenge in Developing Countries - The Benin Experience

We report 51 cases of uterine rupture following unsupervised labour and/or the use of oxytocin in stimulated labour over a twelve-year period (between 1991 and 2002). During the period under review, there were 16041 deliveries, giving a ruptured uterus rate of 3.18/1000 with booked and unbooked patients being 1.87 and 9.63 respectively. This rate, however, rose astronomically between 1998 and 2000 to three times the yearly average, coinciding with a new departmental protocol on oxytocin use in labour. About 65% of the cases were unbooked, and more than 80% of the uterine rupture occurred before the patients presented to our delivery suites. Most of the cases occurred among those between Para 1 and 4 (70.4%), while 29.6% occurred among the grandmultiparas. A previous uterine scar was associated with 68.2% of the cases, while prolonged obstructed labour occurred in 38.6%. Oxytocin use was thought to be responsible for 31.8% of cases. Misoprostol was responsible for one case. Augmented labour accounted for 50% of the indication for oxytocin use. The diagnosis of ruptured uterus was pre-operative in 85% of cases and intra-operative in the rest. There was no post-partum diagnosis of ruptured uterus in the series. About 50% of the patients had repair only while about 27% had hysterectomy, and 9 patients had repair plus tubal ligation. The most common associated injury found at surgery was broad ligament haematoma, closely followed by rupture of the urinary bladder. Maternal mortality in this series was 6.8%. The problems associated with the diagnosis and management of uterine rupture in a developing country is discussed. The need for judicious use of oxytocin, especially in patients with previous uterine scar and in grand-multiparas, and the adequate deployment of experienced obstetricians and experienced midwives in the delivery suits is discussed.

Keywords
Uterine rupture, Obstructed labour, Oxytocin use, Grand multiparity, Maternal mortality