Journal of

Clinical Medicine

Case Report
Unexpected Uterine Rupture—A Case Report, Review of the
Literature and Clinical Suggestions
Wojciech Flis 1,2,† , Maciej W. Socha 1,2, *,† , Mateusz Wart˛ega 3 and Rafał Cudnik 2

1 Department of Perinatology, Gynecology and Gynecologic Oncology, Faculty of Health Sciences, Collegium
Medicum in Bydgoszcz, Nicolaus Copernicus University, Łukasiewicza 1, 85-821 Bydgoszcz, Poland
2 Department of Obstetrics and Gynecology, St. Adalbert’s Hospital in Gdańsk, Copernicus Healthcare Entity,
Jana Pawła II 50, 80-462 Gdańsk, Poland
3 Department of Pathophysiology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz,
Nicolaus Copernicus University, M. Curie-Skłodowskiej 9, 85-094 Bydgoszcz, Poland
* Correspondence: msocha@copernicus.gda.pl
† These authors contributed equally to this work.

Abstract: Background and Objectives: Women with a history of cesarean section are a high-risk group
because they are likely to develop uterine rupture during their next pregnancy. Current evidence
suggests that a vaginal birth after cesarean section (VBAC) is associated with lower maternal mortality
and morbidity than elective repeat cesarean delivery (ERCD). Additionally, research suggests that
uterine rupture can occur in 0.47% of cases of trial of labor after cesarean section (TOLAC). Case
Description: A healthy 32-year-old woman at 41 weeks of gestation, in her fourth pregnancy, was
admitted to the hospital due to a dubious CTG record. Following this, the patient gave birth vaginally,
underwent a cesarean section, and successfully underwent a VBAC. Due to her advanced gestational
age and favorable cervix, the patient qualified for a trial of vaginal labor (TOL). During labor induction,
she displayed a pathological CTG pattern and presented symptoms such as abdominal pain and
heavy vaginal bleeding. Suspecting a violent uterine rupture, an emergency cesarean section was
performed. The presumed diagnosis was confirmed during the procedure—a full-thickness rupture
of the pregnant uterus was found. The fetus was delivered without signs of life and successfully
Citation: Flis, W.; Socha, M.W.;
resuscitated after 3 min. The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at
Wart˛ega, M.; Cudnik, R. Unexpected
1, 3, 5, and 10 min. The uterine wall rupture was closed with two layers of sutures. The patient
Uterine Rupture—A Case Report,
was discharged 4 days after the cesarean section without significant complications, with a healthy
Review of the Literature and Clinical
Suggestions. J. Clin. Med. 2023, 12, newborn girl. Conclusions: Uterine rupture is a rare but severe obstetric emergency and can be
3532. https://doi.org/10.3390/ associated with maternal and neonatal fatal outcomes. The risk of uterine rupture during a TOLAC
jcm12103532 attempt should always be considered, even if it is a subsequent TOLAC.

Academic Editors: Simone Ferrero,

Keywords: VBAC; TOLAC; uterine rupture; cesarean section; induction of labor
Panagiotis Peitsidis, Panagiotis
Tsikouras and Stephanos Zervoudis

Received: 13 April 2023

Revised: 5 May 2023 1. Introduction
Accepted: 12 May 2023
The rupture of the pregnant uterus is an uncommon but highly severe obstetrical
Published: 18 May 2023
event strongly associated with high fetal and maternal morbidity during the peripartum
period. A uterine rupture is the complete division of all three layers of the uterine muscle:
the endometrium, myometrium, and perimetrium. Most uterine ruptures occur during
Copyright: © 2023 by the authors.
late gestation. Uterine rupture has become an important topic in recent years due to the
Licensee MDPI, Basel, Switzerland. increasing percentage of patients being offered a TOLAC. TOLAC refers to a plan to have a
This article is an open access article vaginal birth in any subsequent pregnancy after cesarean labor. Uterine rupture is by far
distributed under the terms and the most dangerous possible complication that can occur during TOLAC. Typically, uterine
conditions of the Creative Commons rupture occurs suddenly and requires immediate critical emergency care for mothers and
Attribution (CC BY) license (https:// neonates. The risk of this life-threatening condition varies from 0.012 to 0.3%, depending on
creativecommons.org/licenses/by/ the region. In less developed countries, the risk of uterine rupture is much higher, mainly
4.0/). due to poor obstetric care. There are many risk factors for an intrapartum uterine rupture,

J. Clin. Med. 2023, 12, 3532. https://doi.org/10.3390/jcm12103532 https://www.mdpi.com/journal/jcm

J. Clin. Med. 2023, 12, 3532 2 of 10

with the predominance of a previous cesarean section [1–3]. Most commonly, it occurs
during a subsequent TOLAC. Research suggests that the risk of uterine rupture may range
from 0.47% to approximately 0.87% during TOLAC [4,5]. However, there are also cases of
uterine rupture in primigravid patients [6].
The rate of cesarean sections (CS) has increased significantly over the past few decades.
Available data show that the rate of CS continues to rise globally, now accounting for more
than 21% of all childbirths [7].
This paper presents a case of uterine rupture after a second TOLAC attempt, together
with a review of the literature and a proposal of clinical suggestions based on this case and
clinical experience.

2. Case Description
In her fourth pregnancy, a healthy 32-year-old woman at 40 + 6 weeks of gestation
was admitted to the hospital due to a dubious CTG record. She complained of mild lower
abdomen pain. The patient’s first child was born by spontaneous delivery. The second
pregnancy was ended by CS due to a breech position, followed by the delivery of a healthy
child by VBAC two years later. She had no significant medical history, and her antenatal
care had been uneventful. During routine CTG recording at hospital admission, the FHR
baseline showed normal variability with accelerations. During the recording, there was a
single deceleration without systolic activity (up to about 80 beats per minute), which was
immediately corrected to normal values. The CTG record was evaluated. No repetitive
decelerations were found. The recording was assessed as normal according to the FIGO
classification [8]. During admission, the patient was clinically stable. Lab results showed
hemoglobin = 10.7 g/dL, white blood cells = 7.72 G/L, platelets = 223 G/L, C-reactive
protein = 1.2 mg/dL, and an activated partial thromboplastin time (aPTT) of 24.4 s. Vitals
were stable. An ultrasound revealed a eutrophic child in the longitudinal occipitoante-
rior position, with an estimated fetal weight of 3300 g and a normal amount of amniotic
fluid. The biophysical profile test score result (Manning’s score) was 10/10. There were
no ultrasonographic signs of abruption of the placenta or placenta previa. Doppler exami-
nation of the umbilical and middle cerebral arteries showed a normal spectrum of blood
flow. Sonographic measurement of the lower uterine segment (LUS) thickness showed
3.4 mm. There was no bleeding or oozing of amniotic fluid during a vaginal examination.
The Bishop score of the cervical examination was >6, with 3–4 cm cervical dilation and
60–70% cervical effacement [9]. During her stay in the pregnancy pathology ward, several
repeat CTG recordings were performed, which showed no disturbing symptoms and were
classified as normal according to the FIGO classification.
Using the VBAC calculator [10,11], the chances of a successful vaginal birth were
estimated at 95%. Due to her advanced gestational age and favorable cervix (Bishop > 6),
the patient qualified for a trial of vaginal labor (TOL). According to the local induction of
labor (IOL) low-dose protocol, an oxytocin infusion containing 5 units in 19 milliliters of a
saline solution was set up. Induction of labor was started with an initial dose of 0.5 mUI/mL,
increasing the dose by 1 mUI/min. After an hour and a half, the patient developed strong
contractions. The labor pain was relieved using Entonox gas (a mixture of 50% nitrous
oxide and 50% oxygen). The woman in labor administered the gas herself through a face
mask connected to a valve, which allowed the patient to inhale fresh gas with each breath.
Gas administration was continued until the end of the contraction, at which point the
patient was breathing room air. Monitoring during labor consisted of a continuous fetal
electrocardiogram and tocometer. In addition, the patient’s vital parameters were measured
periodically. After approximately one hour of regular uterine contractions, abrupt, deep
(up to approximately 50 beats per minute), prolonged deceleration of FHR was observed
(Figure 1). The oxytocin infusion was stopped immediately. In total, the patient received
approximately 300 mUI of oxytocin. During the examination, she complained of increasing
abdominal pain and the abrupt cessation of contractions. Examination revealed a 6-cm
dilated cervix with a preserved amniotic bladder. Subsequently, in order to assess amniotic
 J. Clin. Med. 2023, 12, x FOR PEER REVIEW 3 of 10

J. Clin. Med. 2023, 12, 3532 3 of 10

increasing abdominal pain and the abrupt cessation of contractions. Examination revealed
a 6-cm dilated cervix with a preserved amniotic bladder. Subsequently, in order to assess
amniotic
fluid fluid
staining, anstaining,
amniotomyan procedure
amniotomy wasprocedure was large
performed—a performed—a
amount of large
bloodyamount
amnioticof
bloody amniotic fluid (about 300–350 mL) was obtained. Vital parameters were
fluid (about 300–350 mL) was obtained. Vital parameters were stable. Suspecting a uterinestable.
Suspecting
rupture, the apatient
uterine rupture,
was thetopatient
wheeled was wheeled
the operating room to
forthe
an operating
emergencyroom for an
cesarean emer-
section
gencygeneral
under cesarean section under general anesthesia.
anesthesia.

Figure1.1.CTG
Figure CTGrecording
recordingshowing
showingprolonged
prolongeddeceleration;
deceleration;upper
upperblack
blackline—fetal
line—fetalheart
heartrate
raterecord;
rec-
ord; lower black line—uterine systolic activity; gray line—maternal heart rate record
lower black line—uterine systolic activity; gray line—maternal heart rate record.

Two 16-gauge
Two 16-gauge intravenous
intravenous cannulae
cannulae werewereimmediately
immediatelysecured,
secured,and and1000
1000mLmL of the
of
multi-electrolyte
the multi-electrolyte solution
solutionwas was
infused rapidly
infused priorprior
rapidly to theto
induction of anesthesia.
the induction Induc-
of anesthesia.
tion was conducted
Induction was conducted intravenously with propofol
intravenously and succinylcholine,
with propofol and rapid
and succinylcholine, andtracheal
rapid
intubation was performed. Anesthesia was maintained with
tracheal intubation was performed. Anesthesia was maintained with air, oxygen, air, oxygen, and 2% (1 MAC)and
sevoflurane.
2% (1 MAC) At the same time,
sevoflurane. At thethesame
patient’s
time, blood type wasblood
the patient’s immediately
type was confirmed
immediatelyand 4
units of fresh
confirmed andfrozen
4 unitsplasma
of fresh(FFP),
frozen4 units
plasmaof red blood
(FFP), cell concentrate
4 units of red blood(RBC), and 4 units
cell concentrate
of cryoprecipitate
(RBC), and 4 units of were reserved according
cryoprecipitate to the Holocomb
were reserved accordingalgorithm (the RBC:FFP
to the Holocomb algorithmratio
of 1:1).
(the In addition,
RBC:FFP ratio ofthe availability
1:1). In addition,of fibrinogen concentrate
the availability (hFC) and
of fibrinogen prothrombin
concentrate (hFC) com-and
plex concentrate
prothrombin (PCC)concentrate
complex has been confirmed
(PCC) has asbeen
an emergency
confirmedbridging therapy until
as an emergency blood
bridging
components
therapy until are
bloodavailable.
components are available.
The
Theabdomen
abdomenwas wasrapidly
rapidlyopened
openedby byaaJoel-Cohen
Joel-Cohenincision.
incision.AAsignificant
significantamount
amountof of
bloody
bloodyamniotic
amnioticfluid
fluidwas
wasencountered
encounteredin inthe
theabdominal
abdominaland andpelvic
pelviccavities.
cavities.The Theprevious
previous
cesarean
cesareansection
sectionscar
scarwas
wasruptured
rupturedentirely,
entirely,andandthe
thefetus
fetuswas
waspartially
partiallyoutside
outside thethe uterus.
uterus.
The
Thehead
headandandshoulders
shoulders of ofthe
thefetus
fetuswere
were in inthe
theabdominal
abdominal cavity,
cavity,while
whilethe therest
restof ofits
its
body remained in the uterine cavity. The fetus was delivered without
body remained in the uterine cavity. The fetus was delivered without a fetal heart tone a fetal heart tone
and
andimmediately
immediatelypassedpassedto tothe
theneonatal
neonatalteam,team,whowhosuccessfully
successfullyresuscitated
resuscitatedthe thebaby
babyafter
after
33min.
min. The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at 1, 3, 3,
The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at 1, 5, 5,
and and10
10 min.
min. Theuterine
The uterinerupture
rupturewas wasconfirmed,
confirmed,with with complete
complete damage
damage to to the
the anterior
anterioruterine
uterine
wall
wallfrom
fromthe
theleft
leftto
tothe
theright
rightbroad
broadligament.
ligament.One Onehundred
hundredmicrograms
microgramsof ofCarbetocin
Carbetocinand and
11ggofoftranexamic acid were infused. Blood loss was estimated at 500–600
tranexamic acid were infused. Blood loss was estimated at 500–600 milliliters (mL). milliliters (mL).
The
Thepatient
patientreceived
received1500 1500mL mLofofmulti-electrolyte
multi-electrolytesolution
solutioninintotal.
total. The
Theanatomy
anatomy of ofthethe
uterus was not affected—there was no need for an emergency
uterus was not affected—there was no need for an emergency hysterectomy. The rupturehysterectomy. The rupture
was
wasclosed
closedwith
withtwotwolayers
layersof ofsutures.
sutures.Blood
Bloodand andclots
clotswere
wereremoved.
removed.The Thepatient’s
patient’spelvis
pelvis
showed
showed no other abnormalities. Further examination showed no damage to
no other abnormalities. Further examination showed no damage tothe
theuterine
uterine
ligaments, adnexes, rectum, or urinary bladder. Vital signs (including Shock Index and
mean arterial pressure), hemoglobin, platelet count, clotting times, and lactate levels were
 ligaments, adnexes, rectum, or urinary bladder. Vital signs (including Shock Index and
mean arterial pressure), hemoglobin, platelet count, clotting times, and lactate levels were
J. Clin. Med. 2023, 12, 3532 within the normal range during and after surgery. One hour after surgery, the patient was 4 of 10
extubated in the recovery room and transferred to the maternity ward. The patient was
monitored and placed on intravenous cefuroxime and analgesics after surgery. These
were continued
within thefor four days
normal rangepostoperatively.
during and afterThe patient
surgery. didhour
One not develop any alarming
after surgery, the patient was
signs and symptoms in the postoperative period. The patient made an uneventful
extubated in the recovery room and transferred to the maternity ward. The patient and was
complete recovery and was discharged home after 4 days with a healthy baby (Figure
monitored and placed on intravenous cefuroxime and analgesics after surgery. These 2). were
continued for four days postoperatively. The patient did not develop any alarming signs
and symptoms in the postoperative period. The patient made an uneventful and complete
recovery and was discharged home after 4 days with a healthy baby (Figure 2).

Figure 2. Diagram showing the fluctuations in the patient’s parameters during hospitalization:
hemoglobin (Hb), white blood cells (WBC), platelets (PLT), aspartate transaminase (AST), alanine
transaminase (ALT), prothrombin time (PT), activated partial thromboplastin time (aPTT), C-reactive
protein (CRP).
Figure 2. Diagram showing the fluctuations in the patient’s parameters during hospitalization: he-
moglobin (Hb), white blood cells (WBC), platelets (PLT), aspartate transaminase (AST), alanine
3. Discussion
transaminase (ALT), prothrombin time (PT), activated partial thromboplastin time (aPTT), C-reac-
Pregnant women with a history of CS are considered a high-risk group because they
tive protein (CRP)
are likely to develop uterine rupture. Although the risk of uterine rupture is low, its course
can be extremely dramatic and lead to the death of the mother and her unborn child.
3. Discussion
Furthermore, as seen in the presented example, uterine rupture may not only affect women
Pregnant women with a history of CS are considered a high-risk group because they
who give birth vaginally after a cesarean section for the first time. It also applies to women
are likely to develop uterine rupture. Although the risk of uterine rupture is low, its course
who have already passed a successful VBAC.
can be extremely dramatic and lead to the death of the mother and her unborn child. Fur-
As mentioned above, a large increase in the cesarean section rate over the past few
thermore,
yearsascan
seenbeinobserved.
the presented example, of
The frequency uterine rupture may
CS nowadays means notthat
only affect
most women will
obstetricians
who give birth vaginally after a cesarean section for the first time. It also applies to
encounter VBACs regularly. TOLAC is one strategy to decrease the rate of cesarean births. women
who haveTOLACalready passed a successful
is associated with less VBAC.
maternal mortality and morbidity than ERCD [12,13]. It
Asshould
mentioned
be noted that alarge
above, a increase
successful in the has
TOLAC cesarean section
the fewest rate over theand
complications pastisfew
the safest
years can be observed.
delivery route. In The frequency of
comparison, CS nowadays
ERCD means that
can be associated with most obstetricians
a risk of placentawill accreta in
encounter VBACs
future regularly.
pregnancies andTOLAC is one strategy
pelvic adhesions. to decrease
Factors the ratemost
that contribute of cesarean births.rupture
to the uterine
TOLAC is associated with less maternal mortality and morbidity than ERCD [12,13].
are the induction of labor, a shorter interval between deliveries, previous uterine surgeries, It
shouldmacrosomia,
be noted that a successful TOLAC has the fewest complications and is the
abnormal placentation, and prolonged labor. Amongst possible complications safest
delivery route. Inwith
associated comparison,
TOLAC, ERCD
uterinecan be associated
rupture withwith
is associated a risk
theoflargest
placenta accreta
increase in
in maternal
future and
pregnancies and pelvic[14–16].
neonatal morbidity adhesions. Factors
Typical uterinethat contribute
rupture symptoms mostaretoabdominal
the uterine pain that
begins with a “ripping” sensation, chest pain that may occur if blood enters the peritoneum,
heavy vaginal bleeding, and loss of station of the presenting part of the fetus with cessation
of uterine contractions [17]. However, the pathological CTG (showing FHR abnormalities)
pattern is by far the most frequent (and sometimes the only) symptom [18]. In our case,
the pathological CTG record was the first symptom of upcoming events. Although an
J. Clin. Med. 2023, 12, 3532 5 of 10

incorrect CTG pattern may not provide certainty in the diagnosis of a ruptured uterus, its
presence should lead to raised awareness of the medical team of a possible uterine rupture,
especially during TOLAC [19]. Continuous, uninterrupted CTG monitoring enables the
immediate detection of fetal heart rhythm disturbances, which increases the awareness
of an ongoing uterine rupture. Therefore, we strongly recommend that continuous CTG
monitoring is routinely used in the case of TOLAC.
It is also noteworthy that labor epidural anesthesia may mask the pain associated
with a uterine rupture and lead to a delayed diagnosis [20]. On the other hand, epidural
anesthesia is one of the most favorable prognostic factors of a successful TOLAC.
In addition, it is worth considering that the patient had already successfully undergone
TOLAC. We bring this to attention as the possible cause of the uterine rupture, in this
case, may have been unrecognized uterine muscle incomplete dehiscence during the first
VBAC, and this may have contributed to the extensive dehiscence during the subsequent
TOLAC. Uterine dehiscence is a condition similar to uterine rupture but characterized by
the incomplete division of the uterus that does not penetrate all layers. Such dehiscence
can significantly weaken the uterine wall, making it more susceptible to rupture in the next
delivery. In addition, such a dehiscence may remain clinically silent and be an incidental
finding during a caesarean section [21].
The ultrasonographic evaluation of the lower uterine segment (LUS) can effectively
predict the quality of the uterine scar. A lower uterine segment thickness of less than 2 mm is
considered a criterion for poor healing and differentiates the risk group of potential uterine
rupture with sensitivity and specificity of 86.7% and 100%. In our case, the measurement
of the lower section was 3.4 mm [21–23]. Additionally, a full LUS thickness of 2.3 mm in
women during the first stage of labor is associated with a high risk of complete uterine
rupture during a trial of labor. We believe that measuring the full thickness of the LUS may
be of practical use when deciding on the mode of delivery and may lead to a reduction in the
incidence of uterine ruptures [24]. Despite the high predictive value of this measurement,
in our case, it did not protect the patient from uterine rupture. However, considering the
above, we believe that LUS measurement should be routinely performed in patients after a
cesarean section in order to assess the quality of the cesarean scar and possibly assign the
patient to a higher-risk group for uterine rupture during TOLAC.
Uterine rupture may be associated (in the vast majority of cases) with massive post-
partum hemorrhage (PPH). Bleeding can be the result of massive damage to the uterine
muscle (and surrounding tissues) or the result of atony of the uterine muscle that develops
due to rupture. Traditionally, postpartum hemorrhage (PPH) has been defined as greater
than 500 mL estimated blood loss associated with vaginal delivery or greater than 1000 mL
estimated blood loss associated with cesarean delivery. In our case, no massive bleeding
occurred, and the patient did not develop coagulopathy. In addition, the hemoglobin level
remained stable throughout. This is consistent with the literature that we have reviewed.
Massive hemorrhage is rather associated with the event of uterine rupture, rather than the
complete dehiscence of a previous uterine scar. Additionally, in the literature, a greater
prevalence of bleeding or the need for transfusions after complete dehiscence of a previous
cesarean delivery with associated emergent CS vs. ERCD after the last cesarean delivery is
not clearly evident [25,26].
Despite the fact that, in our case, there was no development of hemorrhagic shock and
coagulopathy, we took all steps to be prepared for such a scenario. Most women die within
the first day of the postpartum period, and as many as 88% during the first 4 h of the onset
of hemorrhage [27]. Therefore, it is crucial to act rapidly in the case of PPH. Expecting
massive bleeding, we secured the essentials of hemorrhage management for immediate
action if needed. During the entire course of the cesarean section, we monitored the patient
on an ongoing basis for the development of coagulation disorders and increased bleeding.
Massive hemorrhage requires the immediate action of the entire medical team. Sus-
pecting uterine rupture, we immediately placed the entire team (including anesthesia and
operating theater (OR) staff) on alert for a possible ongoing, urgent case. We believe that
J. Clin. Med. 2023, 12, 3532 6 of 10

such a model of action significantly reduces the time needed to react and greatly contributes
to improving the quality of care in case of a massive hemorrhage. Furthermore, we believe
that proceeding with TOLAC requires the presence of an experienced team (including
operating room staff and anesthesiologists) capable of an immediate response in the event
of dangerous obstetric events.
In our case, we applied tranexamic acid (TXA) immediately after starting the op-
eration. We believe that the inhibition of fibrinolysis is essential in the event of severe
bleeding. It is of crucial importance to inhibit fibrinolysis via the prompt intravenous
administration of tranexamic acid (TXA) in the event of possible PPH. According to the
reviewed literature, TXA administration is associated with a significant decrease in blood
loss (even up to 50%) and a decrease in the need for blood transfusion [28–31]. TXA is
a safe drug, relatively cheap, and available in most centers. Additionally, recent studies
have shown the high safety of a single administration of up to 4 g of TXA in the context of
massive bleeding [32,33]. In addition, some guidelines even recommend the routine use
of TXA up to 30 min before the planned surgical procedure, to protect the patient in the
event of excessive hemorrhage [34,35]. Considering the above, we recommend that TXA
should always be administered (along with uterotonics) when postpartum hemorrhage is
suspected. In addition, we believe that TXA should be considered before elective cesarean
delivery to reduce estimated blood loss.
It is also worth noting that in the case of severe postpartum hemorrhage (sPPH),
capillary blood analysis may be helpful in order to assess the intensity of hypovolemic
shock [36,37]. Using the critical parameter analyzer, it is possible to quickly assess the
acid–base balance (including base excess parameter) and basic parameters such as the
hemoglobin level. In addition, such a test may have predictive value in assessing the
adaptation of the circulatory system to ongoing hemorrhage. Therefore, we strongly
recommend the use of this quick and cheap test to assess the severity of hemorrhage in the
presence of ongoing sPPH.
Another catastrophic complication of uterine rupture that can occur is amniotic fluid
embolism (AFE) [38,39]. AFE is characterized by a breach of the barrier between the mater-
nal blood and amniotic fluid that forces the entry of amniotic fluid, fetal cells, or other debris
into the systemic circulation, causing cardiovascular collapse and acute coagulopathy. AFE
is an extremely rare complication—its occurrence is estimated at about 1 in 80,000 deliver-
ies. However, its occurrence is associated with catastrophic consequences and a very low
survival rate [39]. The rapid course of AFE and its often irreversible consequences force
clinicians to act immediately. According to the latest research, in the case of this dangerous
complication, the use of the atropine–ondansetron–ketorolac (AOK) algorithm may prove
effective and may improve the patient’s prognosis [40]. We believe that the AOK scheme
could be successfully supplemented in the current AFE management guidelines. We raise
this topic because we strongly suggest that in the event of such emergencies as a rupture of
the uterine muscle, the possibility of AFE should be additionally taken into account.
There are many risk factors for uterine rupture. However, referring to the literature,
the dominant risk factor for rupture of the pregnant uterus is a history of previous uterine
surgery. The largest percentage of uterine ruptures is caused by surgical treatment of
uterine fibroids (especially with the opening of the endometrial cavity). Regardless of
the method of myomectomy (hysteroscopy, laparoscopy, or laparotomy), there is a large
positive correlation between a history of uterine surgery and uterine rupture. An additional
risk factor is the mere presence of large uterine fibroids (with a maximum diameter above
4 cm). Interestingly, the risk of uterine rupture after laparoscopic or abdominal laparotomy
is highest in the third trimester of pregnancy. In contrast, the risk of uterine rupture after
hysteroscopic myomectomy is more common in the earlier gestational ages. Surprisingly,
uterine rupture during pregnancy after abdominal myomectomy seems to be less frequent
than after a laparoscopic one [41–43]. Taking all the above into consideration, we believe
that it is mandatory to consider the eventuality of uterine rupture in pregnancy (particularly
in the third trimester) regardless of the type of uterine surgery performed.
J. Clin. Med. 2023, 12, 3532 7 of 10

Induction of labor with oxytocin infusion is certainly a risk factor for intrapartum
uterine rupture. According to the studies conducted, induced labor may increase the risk of
uterine rupture during TOLAC. The rate of uterine rupture in women attempting TOLAC
with induced labor is slightly higher than with spontaneous labor (2.2% vs. 0.7%) [44].
However, in our case, considering the clinical situation, oxytocin infusion was the procedure
of choice. The safest of the recommended procedures was selected using a low-dose
oxytocin dosing regimen (in accordance with Polish recommendations). At the same time,
we conducted continuous monitoring of the patient and fetus.
Factors associated with a statistically significantly increased likelihood of VBAC are the
following: previous VBAC, white race, fetal malpresentation as the indication for a previous
cesarean section, estimated fetal weight less than 4000 g, gestation age 37–40 weeks, and
spontaneous labor. Although the patient met most criteria for a successful TOLAC, this
did not protect her from uterine rupture. Therefore, we believe that no matter how many
criteria patients meet, the possibility of uterine rupture should always be considered when
attempting a TOLAC [45,46].
Thanks to the raised awareness and the knowledge of the typical symptoms and
risk factors of this dangerous event, uterine rupture was our primary diagnosis. Taking
quick, decisive action prevented the occurrence of significant fetal complications and
prevented the occurrence of a dangerous hemorrhagic shock, which could have led to the
patient’s death.

4. Conclusions
Overall, despite its rarity, specifying and pointing to individual cases of uterine
rupture should make clinicians aware that the problem of intrapartum uterine rupture is
extremely important and still often encountered in everyday practice. A previous successful
TOLAC may falsely alleviate the vigilance of the medical staff, which may have disastrous
consequences. Therefore, we believe that regardless of the number of previous VBACs, it is
crucial to always show extreme vigilance, analyze the risk factors, and conduct constant
monitoring of both the mother and the fetus. Thanks to this, even in the event of this
dangerous complication, it is possible to take immediate therapeutic action.

5. Clinical Suggestions
Here, we would like to present clinical suggestions on how to manage vaginal delivery
after a cesarean section, which are based on the reviewed literature and our personal
clinical experience.
- The lower uterine segment should be routinely measured to assess the continuity of
the uterine scar. Consider disqualifying a patient from TOLAC if LUS measurement is
<2 mm.
- Continuous CTG monitoring should be routinely used in any case of TOLAC.
- Uterine rupture should always be considered in the presence of an abnormal CTG,
vaginal bleeding, or abrupt cessation of contractions during TOLAC.
- Regardless of the severity of bleeding in the event of uterine rupture, all components
of the hemorrhage management algorithm should always be secured to minimize the
time needed to implement them.
- When uterine rupture or heavy bleeding is diagnosed, administer TXA intravenously
immediately (along with uterotonics).
- Although a history of VBAC reduces the risk of uterine rupture in a subsequent
pregnancy, any patient undergoing IOL should be considered at increased risk for
uterine rupture.
- Patients who have undergone previous uterine surgery (regardless of the surgical
method) should be treated with extreme caution due to the high risk of uterine rupture
during labor.
J. Clin. Med. 2023, 12, 3532 8 of 10

- The fulfilment of the predictors of successful vaginal delivery after cesarean section
should not change the means of monitoring the patient. Such a patient should continue
to be treated as a high-risk patient for uterine rupture.
- In the event of uterine rupture, the possibility of AFE should be considered.
- In the event of sPPH, we strongly recommend to use capillary blood test analysis to
assess the intensity of hypovolemic shock.
- Proceeding with TOLAC requires the presence of an experienced team (including
obstetrician, OR staff, and anesthesiologists) capable of an immediate response in the
event of dangerous obstetric events.

Author Contributions: Conceptualization, W.F. and M.W.S.; methodology, W.F. and M.W.S.; software,
R.C.; validation, W.F., M.W.S. and M.W.; formal analysis, W.F. and M.W.S.; investigation, M.W.S., W.F.
and M.W.; resources, W.F. and M.W.S.; data curation, W.F. and M.W.S. and R.C.; writing—original
draft preparation, W.F. and M.W.S.; writing—review and editing, W.F. and M.W.S.; visualization, R.C.;
supervision, W.F. and M.W.S.; project administration, W.F. and M.W.S.; funding acquisition, W.F. and
M.W.S. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Ethics Committee of Collegium Medicum in Bydgoszcz,
Nicolaus Copernicus University (KB 37/2023).
Informed Consent Statement: Written informed consent has been obtained from the patient(s) to
publish this paper.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to privacy restrictions.
Conflicts of Interest: The authors declare no conflict of interest.

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