Birthrites: Healing After Caesarean.

Uterine Rupture.

By Debbie Miller.

My name is Debby Miller. I am a thirty something mother of two boys. One born by caesarean and the other a VBAC.

I work full time as a financial adviser in a Government Department and am currently studying two degrees Accounting and Human Resource Development. From my work and study I have developed a good ability to research things. A skill that was particularly helpful to me when I was researching for my VBAC birth.

I have a great interest in birth issues, particularly related to being an informed patient because of my first bad birth experience and my subsequent good one.

I have offered to write a series of articles about a variety of subjects for Birthrites in the hope that my experiences and investigative abilities can help other mothers and mothers to be to make informed decisions about their birth choices. The topics I intend to write about are shown in the Discussion Topics Index. I will not be writing them in any specific order or to any specific time frame.

I would advise all readers to read the first article Believing What You Are Told as this provides the basis for you to understand how assessments are made, both by myself and in the references I use, on the remainder of the topics discussed.

I will try to keep the articles simple and will provide examples where possible. If medical terms are used I will add them to the Glossary so you can see what they mean.

I would ask that readers note that I will try to keep the research factual and not input my own personal bias, however whilst I am aware of my own prejudices, I will probably lean towards documentation that supports my view.

Secondly I am not a medical practitioner, nor do I have any medical training. The information I present will be based on research, journal articles and texts, and my interpretation of those. I will quote all references. Women wishing to use the information I provide are recommended to read the references for themselves and should discuss any issues pertaining to their own medical management with a qualified medical practitioner or midwife.

UTERINE RUPTURE

A Quick Anatomy Lesson

In introducing the topic of uterine ruptures we first need to have a bit of understanding of how the uterus works. The uterus has three sections:

The upper segment Also called the fundus. This area is the main body of the uterus in which the baby grows. The upper segment is made of a criss-cross of muscles on the outside and the endometrium (lining) on the inside. In the majority of pregnancies this is the area where the placenta is attached. During labour the muscles of the upper segment contract. With each contraction the muscle fibres get a little shorter. This results in the lower segment being pulled upwards and causing the cervix to open.

The lower segment The lower segment is the area that joins the upper segment to the cervix. It has a relatively lower blood supply than the upper segment. In the non-pregnant woman and the early stages of pregnancy the lower segment is hard to distinguish from the cervix as it is so small. In late pregnancy the lower segment starts to stretch upwards as the baby grows and can be clearly defined by the end of the third trimester. It is through the lower segment that most csecs are done these days as the risk of bleeding is significantly lower. During labour the lower segment is stretch up by the contractions of the upper segment and this causes the cervix to open. By the end of labour (full dilation) it is very difficult to distinguish the cervix from the lower segment.

The cervix is the band of tissue which keeps the uterus closed during pregnancy. During labour the cervix is stretched open by the pulling on the lower segment from the contractions and by the pressure of the baby's head. By the end of labour (full dilation) the cervix will have stretch to a diameter of 10cm and the baby's head can then pass through into the vagina and the outside world.

What are Ruptures and Dehiscence?

A rupture is a 'disturbance' in the wall of the uterus. It may be minor when it is also known as a dehiscence or window or it may be major. A dehiscence or window usually refers to an opening that is very small or does not go through all of the layers of the uterus.

A rupture is a large tear that goes through the full thickness of the uterus.

Where do Ruptures and Dehiscence Occur?

A rupture can occur anywhere on the uterus. The two most common sites are where there is an old scar or at the line where the lower segment joins the upper segment. Just because a woman has had a previous csec does not mean she will rupture at the site of the scar. In one study (ref 23) only 68% of women with ruptures ruptured at the site of their previous scar.

When do Ruptures Occur?

Ruptures can occur before or during labour. The statistics for this are quite divergent. In one study (ref 4) they indicated that 10% of ruptures occurred before labour commenced. In ref 10 they quote a study in which 23% of ruptures occurred before labour started and they quote the American College of Gynaecologist who state the rate is as high as 50%.

What happens if there is a Rupture or Dehiscence?

If a dehiscence occurs usually nothing happens. The majority of them are found after successful vaginal birth when the doctor feels inside the uterus (not a common practice any more and it is not recommended as it increases the risk of infection with no appreciable benefit). Occasionally they are found in women having an elective repeat csec and in women having an csec after failed VBAC. All the writings I read indicate that there is usually no action taken to repair them as they tend to heal well by themselves, and it is acknowledged they present no risk to the mother or baby.

Ruptures can occur in the upper or lower segment or where the two join. A rupture in the upper segment is the most catastrophic as this area has a large blood supply. If a rupture occurs the baby may move out of the uterus into the abdominal cavity. This is very dangerous for both the mother and the baby as it places tension on the placenta, which can cause it to separate from the uterine lining. If this occurs the mother will lose even more blood and the baby loses its oxygen supply. (Fortunately the incidence of this is very low and is explained later in this article).

A rupture in the lower segment is less catastrophic as this area has a lower blood supply and the bladder will inhibit (but not necessarily stop) the ability of the baby to leave the uterus. This is however still an emergency situation requiring immediate intervention.

How Accurate are Doctors at Identifying Ruptures?

I could only find one study,(in Massachusetts ref 23), that addressed this. Over a seven year period they had 1244 cases that were identified as suspected dehiscence (in this study dehiscence was used to describe both windows and ruptures), of these only 480 (38%) were confirmed as uterine ruptures. The literature suggests that the incidence of picking up a true rupture is very high however the incidence of mistaking certain symptoms for a rupture when there isn't one is also very high.

What are the Symptoms of Rupture or Dehiscence?

With a dehiscence there are usually no symptoms at all. In some cases it is believed that the window is actually a failure of the csec scar to heal rather than as a result of the pressures of labour. Reference 12 indicates there is no risk to the mother or baby.

If a rupture occurs there can be a number of symptoms. All or none of these may be present (refs 1,2,4,11, 20 and 21),

the symptoms are:

a. vaginal bleeding

A small amount of vaginal bleeding during labour is normal. Your birth attendants will know if the amount is excessive or not. Vaginal bleeding can also occur where the placenta partly or fully detaches from the uterusbefore the baby is born (this is not a rupture but is an emergency) or where there is a tear in the vagina or cervix from the pressure of the baby or from attempts at instrument deliveries (forceps and vaccuum).

b. hypotension

This is low blood pressure, it causes dizziness and lethargy and occurs during ruptures because of blood loss but can also be caused by epidurals, laying down or from medication.

c. cessation of labour

Labour may cease during a rupture because the muscle tissues that have torn areno longer able to contract. Labour may also cease if there is a false labour, the mother is nervous or tense and some labours are known just to 'rest'.

d. loss of intra-uterine pressure

This is were the contractions diminish in intensity (or stop). The reasons for this are the same as for cessation of labour.

e. abdominal or uterine pain

During a rupture this pain may occur for two reason, firstly the tear itself and secondly because blood loss into the abdominal cavity irritate the lining of the cavity. Abdominal pain may also occur as part of normal labour (because contractions do hurt) or because of wind in the bowel or constipation.

f. fetal distress

Where there is a loss of fetal heart rate, a prolonged deceleration (down to 90 beats per minute for more than one minute) or persistent late decelerations there is an indicator that the baby is not receiving enough oxygen for some reason. This may be due to rupture, a problem with the placenta, pressure on the cord, low blood pressure in the mother or a whole range of other reasons.

g. uterine fundus may feel boggy

The uterus normally feels like this after delivery of the baby. It feels like this and tender after a rupture when the baby has partly or fully 'escaped' from the uterus into the abdominal cavity.

h. The fundus may seem to be expanding

This can occur because the cavity is filling with blood from a rupture or because expanding the baby is turning.

i. The woman is aware of something

This may be because of a rupture or it may just be from the baby moving down 'having given way' inside or gas or faeces moving through the bowel.

 

j. When examining the abdomen the baby can be felt very clearly.

The sensation of feeling a baby inside the uterus and one in the abdominal cavity is quite different according to a number of the references. This would therefore only occur if the baby has escaped through a rupture or had grown outside the uterus (extremely rare I have only read of two cases in the world).

k. The woman goes into shock.

This occurs during rupture from blood loss, low blood pressure and possibly from pain. Shock can be caused by any number of things including emotional trauma ie if the mother is particularly frightened during the labour (this causing shock however is very rare. ) Shock can be a life threatening condition it should therefore be treated promptly.

l. Maternal tachycardia

This is fast heart rate (usually above 120 beats per minute in an adult). this is a symptom of shock but can also occur during times of physical exertion (particularly if the mother is unfit) or when the mother is anxious.

Which Women Have Ruptures?

Any woman can have a rupture. This includes women who have never had a csec before. The risk to some women is however higher than for other women. Here is a breakdown (refs 1,2,3,5,6,7,10,16,17,,20,21,22,23,27,28):

  • Of all women who go into labour the risk of rupture is 0.017 - 0.07%
  • Of all women with a previous CSEC the risk of rupture is 0.068 - 1%
  • If the previous CSEC was ;
    • - classical 4 - 9 %

    - horizontal lower segment 0.2 - 1%

- vertical lower segment 1 - 7%

- T or J incision 4 - 9%

  • The risk for women who have had five or more pregnancies (grand multiparity) is also recorded as being higher there were no quoted statistics in any of the articles. In ref 20 they had 13 ruptures and 2 of these were due to grand multiparity.
  • There is also a risk of rupture where there is a trauma to the abdomen. A number of the studies cited ruptures resulting from vehicle accidents.
  • If you had a first trimester abortion (at some time) your risk of rupture is 1%
  • If you have had a hysterotomy or uterine operation (eg fibroid removal) your risk is 6%

Of all uterine ruptures recorded in four studies:

Study one 42 ruptures 71% VBAC 29% in unscarred uterus
(ref 5)

Study two 23 ruptures 43% VBAC 57% in unscarred uterus
(ref 17)

Study three 480 ruptures 92% VBAC 7% in unscarred uterus
1% in non csec scarred uterus
(ref 23)

Study four 81 ruptures 89% VBAC 11% in unscarred uterus
(ref 27)

(These studies do not breakdown what types of scars the VBAC had and do not distinguish between ruptures and dehiscences).

It should be noted that in a number of the references there was no indication if the women who were recorded with ruptures had been in labour or not.

I could not find any studies in references that indicated a higher risk of rupture in women with macrosomic (large over 4kg) babies, twin pregnancies or breech deliveries. Ref 33 indicates there were no significant differences in death or injury in VBAC women with babies over 4kg, it also indicated of the recorded twin VBACs there were no ruptures and of the recorded breech there were no significant differences, however it indicated the preference was to do external version on breech babies. (Also a safe practice for VBAC mothers).

Can They Predict If I Will Rupture?

Ref 10 quotes a British study that involves measuring the thickness of the lower uterine segment by ultrasound late in the last trimester of pregnancy (over 35 wks). The study indicates that in women with the thickest lower uterine segments there is a very low chance of rupture. However the study also acknowledges that even for women with the thinnest lower uterine segments the risk of catastrophic rupture is still very small and can be offset with vigilant labour monitoring.

There are no major studies on the identification of a dehiscence however in this same study the sonographers believed they would be able to see dehiscence at the scar site using ultrasound. Given that dehiscence are considered benign I would wonder what the benefit of this would be as there are no studies that correlate the presence of dehiscence with a higher rupture rate, (mind you there are also none that disprove it either).

What Causes a Rupture?

The simple answer here is we do not know. We know certain factors increase the risk but we do not know why some women have ruptures and others with similar histories do not.

The main factor that has been identified as increasing the risk of ruptures is the use of inducing drugs, oxytocin, prostaglandin and pitocin. A number of the studies indicate statistics associated with the use of these:

  • 6 ruptures 4 (67%) had pitocin (ref 7)
  • 17 ruptures 9 (53%) had oxytocin (ref 13)
  • 31 ruptures 10 (33%) had oxytocin and 4 (13%) had pitocin (ref 17)
  • 13 ruptures 4 (31%) had oxytocin and 3 (23%) had prostaglandin (ref 20)

It should be noted that none of these studies indicate the amount of the drug these patients were given. This is a very important factor as there is a huge difference in the intensity of contractions depending on the rate of induction with oxytocin, and pitocin and prostaglandin have been known to bring on very strong contractions after more than one dose. In support of this ref 5 and 8 both recommend extreme vigilance where more than one dose of pitocin is used, and all of the above references recommend careful monitoring and/or observation of induced women, in particular VBAC and but also non VBAC.

In contrary to these studies, the study in ref 12 found no increased incidence of rupture between those mothers who did and did not receive inducing drugs, and the findings in the study in ref 24 were inconclusive but recommended a proper trial be done on prostaglandins.

Ref 9 raised a very important issue, that is the overuse of induction agents. The author indicates that a number of studies have shown that TOL VBACs ' often have a stop-start labour and they are 'classically slow '. The author goes on to say:

'There is an overuse of induction drugs in an attempt to speed up and 'normalise' the labours of TOL VBACs. It is documented that in TOL ', it is stated that 'women's bodies seem to know that too much stress is bad for their scarred uteri. Yet instead of trusting VBAC mother's bodies intuitive attempts at gentle birth, drugs are given to normalise and speed up the birth process thereby creating more risk of uterine rupture.'

(I would agree with this principle of your body knowing what it is doing. My VBAC started went for 10 hours, stopped for 6 hours restarted, took another 15 hours to get to 4 -5cm then another 12 hours before my healthy son was born. No rupture, no induction, happy Mum.)

I found no studies that indicated epidurals or any other form of pain relief was associated with increased ruptures. Nor was any of the other 'things' Mums do in labour, eg. Walking, showering, bathing, eating, drinking, massage, aromatherapy, etc.

Ref 28 investigated the position of the placenta in relation to rupture sites. They found that of 42 VBAC ruptures, that ruptured at the site of the scar, the placenta was at the site of the rupture in 60% of the cases. They concluded that the position of the placenta may play a role in uterine rupture but indicated further studies were needed to prove this.

What Do they Do If They Suspect a Rupture?

A rupture can (in some cases) result in the death of the baby and/or the mother. The suspicion of a rupture is therefore treated very seriously. All of the references I read recommended immediate action and caesarean section. The types of actions that may be taken included putting in a drip (if there isn't one) to give the mother fluids and possibly blood, administering oxygen by mask and rolling the mother onto her left side. During this time they would also be monitoring the mother's blood pressure and pulse, and the babys heart rate either with an electronic monitor, scalp monitor or by a hand held monitor. They may try to prevent the baby from 'escaping' the uterus by manually holding the baby in the uterus and preparation would be underway to give the mother general anaesthetic so the baby can be delivered by emergency caesarean section very rapidly. (Ref 1, 2, 3 and 10)

What are the Outcomes of Ruptures?

Thankfully the majority of women who experience a rupture leave the hospital with themselves and there babies intact. There are a number of possible procedures that may/will need to be done in the event of a rupture.

It is likely the mother will need the rupture repaired (unless it is found at the time of csec it is only a dehiscence or nothing at all, but even then they will still need to repair the csec incision), she may need an arterial ligation which is where they clamp an artery for persistent bleeding, and in the worse cases (where the bleeding cannot be stopped) she may need a hysterectomy. There are cases of mothers dying from ruptures (very few as you will see below), the primary cause of death in these cases being cardiac arrest from blood loss. (Ref 1)

The outcomes for the baby are simpler but possibly longer lasting. In most cases the baby is perfectly fine. In some cases the baby may suffer some brain damage due to oxygen deprivation, (particularly if they partially or fully 'escape' from the uterus and therefore compromise their placenta), the degree of damage can vary depending on the length of time they were without oxygen and the strength of the baby. (It should be noted that even babies who aren't subject to a uterine rupture can suffer oxygen deprivation in some circumstances, including csec babies). The worst that can happen is the baby will die, usually because its placenta detaches from the uterus and their oxygen supply is completely cut off.

So how often do these things occur:

Study 1 9 ruptures 2 still born (22%)
(of the nine ruptures there were 2 classical csecs and 6 LSCS and one non scarred, the study does not say which of these mothers lost their babies)
0 hysterectomies and 0 maternal deaths
(ref 7)

Study 2 155 ruptures 8 fetal deaths (5% - 5 occurred in mothers who arrived at hospital ruptured)
1 maternal death (doesn't indicate if this was a TOL or unscarred)
(ref 10)

Study 3 17 ruptures 0 deaths 8 hysterectomies (ref 13)

Study 4 1 rupture 0 deaths (this rupture was in an elective repeat csec)
(ref 14)

Study 5 23 ruptures 0 deaths
(ref 18)

Study 6 13 ruptures 0 deaths
(ref 20)

Study 7 8 ruptures 1 fetal death (12.5%) 2 severe fetal asphyxia (oxygen deprivation) 3 bladder lacerations 1 hysterectomy
(ref 22)

Study 8 10 ruptures 2 fetal deaths (20%)
(ref 26)

Study 9 81 ruptures 2 maternal deaths (2%) (these were a mix of scarred and unscarred uterus) 14 bladder injuries 12 hysterectomies 5 fetal deaths (6%) 14 neonatal deaths (17% - after birth deaths - the cause of these deaths is not given) 59 fetal brain damage (72% - the degree of damage is not indicated and it does not indicate if the 14 neonatal deaths are also included in this group)
(ref 27)

If we add all of this up we have 317 reported ruptures, 30 (9.5%) fetal death rate, 3 (0.95%) maternal death rate and 61(19%) of babies with some degree of brain damage from oxygen deprivation (this may be minor or major).

To put this into perspective given that the VBAC mothers risk of rupture is around 1% , you have a (0.095%) chance of your baby dying due to rupture in any VBAC delivery, a 0.0095% of you dying due to rupture in any VBAC delivery and a 0.19% chance of your baby suffering brain damage due to a rupture in any VBAC delivery. (Contrast this to the other risk identified below).

The studies all indicated that one of the primary causes of death amongst mothers and infants was mismanagement by hospital staff. A number of the reports sited ignorance among staff of the symptoms of rupture and/or a slowness to act thus compromising both the mother and the child. The generally agreed treatment was that csec needed to be conducted within 30 mins of suspected rupture with some practitioners indicating this figure should be closer to 17 mins.

What Can Be Done to Reduce the Risk of Rupture?

Either you are going to have a rupture or you are not. There is nothing with the possible, exception of refusing induction agents, that you can do that will reduce your personal risk of rupture.

The key thing in deciding what sort of birth you want to have is to make a conscious decision of the risk YOU are willing to take. To put this into perspective lets look at some comparative risks.

  • Your risk of rupture from a horizontal LSCS scar is: 1% = 1 in 100 VBAC deliveries (this is the highest statistic)
  • Your risk of being diagnosed with dystocia (baby too big) is: 10 - 12% = 10 in 100 vaginal deliveries
  • Your risk of a breech baby at full term is: 3 - 7% = 3 in 100 deliveries
  • The risk of your baby being diagnosed with fetal distress during labour: 2% = 2 in 100 deliveries
  • Your risk of having twins is : 0.4% = 4 in 1000 births
  • Your risk of dying from a rupture of the uterus is: 0.0095% = 9.5 in 100 000 VBAC deliveries
  • Your risk of dying during any vaginal delivery is: 0.0098% = 9.8 in 100 000 vaginal deliveries
  • Your risk of dying during an uncomplicated vaginal delivery is: 0.0049% = 4.9 in 100 000 uncomplicated vaginal deliv.
  • Your risk of dying during any ceasarean section is: 0.0409% = 40.0 in 100 000 ceasarean sections
  • Your risk of dying during an elective repeat ceasarean section: 0.0184% = 18.4 in 100 000 elective csecs
  • The risk of your baby developing cerebal palsy is: 0.25% = 2.5 in 1000 births
  • The risk of your baby developing cerebal palsy after fetal distress: 2.84% = 2.8 in 100 fetal distress births
  • The risk of your baby dying from a rupture of the uterus is: 0.095% = 9.5 in 10 000 VBAC deliveries
  • The risk of your baby dying during any VBAC delivery is : 0.2% = 2 in 1000 VBAC births
  • The risk of your baby dying during any type of delivery is: 0.12% = 1.2 in 1000 births
  • Risk of losing the baby in a breech delivery is: 1 - 4% = 1 in 100 breech deliveries

(ref 10, 33)

Of 873 fetal deaths in the UK during 1994 - 95, 42 (4.8%) were due to uterine rupture 30 of these were in mothers with a csec scar and 12 were in unscarred uterus. (ref 5)

As you can see the risk of you or your baby dying from a uterine rupture is no higher and in some cases lower than it is from 'normal' or caesarean delivery. All births have some degree of risk even if you have a perfect history, the key thing is to identify what you consider too great a risk and then take actions so that you can receive the best possible care if your worse case happens. The big thing to remember when putting this in perspective is that sometimes (thankfully rarely in western countries) mothers and babies die both at hospital and in home births. There are risks of being in hospital (such as the higher chance of intervention and infection) and risks with being at home (such as longer time to get to a place where you can receive emergency resuscitative procedures). It is up to you where you think you will be safer, and what sort of labour you think will be safer (ie. with or without interventions). From the statistics you can see that any doctor that tells you that a certain way is risk free is lying. The only risk free way to have a baby is to adopt.

The best thing you can do if the risks really worry you is to ensure you are in an environment where if a rupture does occur it can be promptly dealt with. This environment would usually be a hospital or a birthing centre. If you are in hospital you may ask for intermittent or continuous monitoring, which is the most reliable (but not 100% accurate) in the indication of a possible rupture. Monitoring can also be done during birthing centre and home births but it is usually intermittent with a stethoscope for fetal sonagraph. Other actions such as epidurals and drips will not make an emergency caesarean any quicker. An emergency caesarean from a rupture would normally be done under a general anaesthetic anyway, and a drip can be put into a person in a couple of minutes or less.

Conclusion

A rupture of the uterus is a very serious condition that needs to be dealt with immediately to save both the mother and baby, however it is rare. Being a VBAC mother does not mean you are the only one who is at risk of a uterine rupture, any woman with or without a uterine scar has some risk of having a rupture.

The likelihood of a fatal outcome from a uterine rupture is no higher than the general incidence of death in all births and is lower than that for caesarean births.

It is recommended that you discuss this issue with your medical practitioner or midwife. They may provide additional studies that counter these findings however the facts found by myself indicate that the risk of uterine rupture in a VBAC birth is very low and the risk of an adverse outcome even lower. In fact these results seem to be no worse than for other means of delivery and for other possible birth complications that can happen to any delivering mother.

References

  • Peripartum haemorrhage by Dr Sanjay Datta, MD, FFARCS
  • Common Peripartum Emergencies by Dr Elizabeth Morrison American Family Physician Journal Nov 1 1998
  • Once a CS always a Controversy by Dr B L Flamm ACOG Journal Vol 90 No2 Aug 97
  • The Risks of Lowering the Caesarean Delivery Rate by Dr B Sachs MB, BS, DPH, Dr C Kobelin, MD, Dr Mary Ames Castro, MD and Dr Fredric Frigoletto, MD, The New England Journal of Medicine, 7 Jan 1999, Vol 340 No.1
  • Induction of Labour and Uterine Rupture by Dr R Foon SHO, CESDI Steering Group 5th annual report 1997: 63-71
  • Vaginal delivery after previous csec remain relatively safe by Dr Gregory and Dr L Korst, MD and Dr P Cane PhD Obstetrics and Gynaecology 94(6), Dec 99 pp 985-989
  • Coombe Women's Hospital Obstetric Report 1998
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  • Will VBAC become a way of the past OBCNEWS Issue 15.3, 13 Jul 1999
  • ICAN /VBAC / Caesarean Webpage
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  • VBAC - Vaginal Birth After Caesarean or Very Big Authority Challenge? by B. Beech and P Thomas, AIMS Journal, Vol 8 No. 1 30 Apr 96
  • Cases of Uterine Rupture and Subsequent Pregnancy Outcome by Al Sakka, Dauleh and Al Hassani of the Hamad Medical Corporation. International Journal of Fertility & Womens Medicine Nov-Dec 99.
  • Delivery after Scarred Uterus at the University Hospital Centre of Dakar by Cisse, Ewagnignon, Terolbe and Diadhiou Journal de Gynecologie, Oct 99
  • Vaginal Birth after Caesarean and Uterine Rupture Rates in California by Gregory, Korst, Cane, Platt and Kahn. Obstetrics & Gynochology Dec 99
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  • Intrapartum rupture of the unscarred uterus by Miller, Goodwin, Gherman and Paul. Obstetrics and Gynecology May 97.
  • Risk Factors Associated with Uterine Rupture during TOL after CSEC by Leung, Farmer, Leung, Medearis and Paul. American Journal of Obstetrics and Gyynecology May 93
  • Rupture of low transverse csec scars duritng trial of labour. THe Journal of the American Medical Association 18 Sep 91
  • Use of Hospital Discharge Data Monitor Uterine Rupture - Massachusetts 1990 - 97. Morbidity and Mortality Weekly Report 31 Mar 2000
  • Use of Prostaglandins to induce labour in women with Csec scar by Vause and Macintosh. British Medical Journal Apr 17 1999.
  • Csec Scar dehiscence following vaginal delivery by Connoly and Byrne. Journal of Obstetrics and Gynaecology Vol 19 No 6 1999
  • Trial of Labour after Csec by McMahon, Luther, Bowes and Olshan. New England Journal of Medicine 1996.
  • Catastrophic Uterine Rupture: Maternal and Fetal Characteristics by Kirkendall, Jauregui, Kim and Phelan. Obstetrics and Gynecology 2000
  • Uterine Rupture: A placentally Mediated Event? by Jauregui, Kirkendall, Ahn and Phelan. Obstetrics and Gynecology 2000
  • Uterine Rupture During a Failed Trial of Labor: Are There Any Identifiable Risk Factors in Labor Management by Burke, Lee, Harish, Sehdev and Ludmir. Obstetrics and Gynecology 2000
  • Vaginal Birth After Prior Cesarean by Dr C Brittan. Jul 99.
  • Delivery After Previous Csec: A Risk Evaluation by J Rageth. Obstetrics and Gynecology 1999.
  • Medical Abortion Complications by D Nemec Obsterics and Gynecology Apr 78
  • Cesarean Section: Guidelines for Appropriate Utilization by Dr B Flamm and Dr E Quilligan.

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