Obgyn · Year 3 · from Obgyn
Case 2: Trial of Labor After Cesarean (TOLAC) Complicated by Uterine Rupture
Patient Demographics
- Age: 33 years
- Sex: Female
- Occupation: Pharmacist
Chief Complaint
"I'm having contractions and I want to try for a vaginal delivery this time."
History of Present Illness
The patient is G2P1 at 39 weeks 1 day with spontaneous onset of labor. Her prior pregnancy resulted in a cesarean delivery for breech presentation at 39 weeks (low transverse incision confirmed by operative report). She desires TOLAC. She has been contracting regularly for 4 hours and presents for admission.
Prenatal Course
- Uncomplicated pregnancy
- TOLAC counseling completed at 36 weeks
- Reviewed operative report: confirmed low transverse incision
- Discussed risks and benefits, signed consent for TOLAC
TOLAC Candidacy Assessment
- Prior low transverse cesarean incision: YES
- Non-recurring indication (breech): YES
- Singleton vertex pregnancy: YES
- Spontaneous labor onset: YES
- Interpregnancy interval >18 months: YES (30 months)
- Estimated success rate: 70-75%
Admission
- Cervix: 4 cm, 90% effaced, -1 station
- FHR: 140 bpm, moderate variability, accelerations present
- Contractions: Every 3 minutes, strong by palpation
- IV access established, type and screen current
- Anesthesia aware, epidural placed for labor analgesia
Labor Progress
Hour 3:
- Cervix: 6 cm
- FHR: Reactive, no decelerations
- Contracting well, no augmentation needed
Hour 5:
- Cervix: 8 cm
- FHR: Variable decelerations, quickly recovering
- Patient comfortable with epidural
Hour 6 - ACUTE EVENT:
- Patient reports sudden, severe abdominal pain "different from contractions"
- States pain persists even between contractions
- Epidural in place, but she rates pain 9/10 despite it
Immediate Assessment:
- FHR: Prolonged deceleration to 60 bpm
- Maternal HR: 110 bpm (new tachycardia)
- Abdominal exam: Diffuse tenderness, uterine contour difficult to palpate
- Vaginal exam: Cervix still 8 cm, presenting part now at -3 station (was -1)
- Loss of fetal station noted
Diagnosis
Suspected Uterine Rupture
- Classic triad: sudden severe pain, FHR abnormality, loss of station
- Prolonged fetal bradycardia not recovering
Emergency Cesarean Delivery
Decision-to-incision: 8 minutes (crash cesarean)
Operative Findings:
- Pfannenstiel incision through prior scar
- Upon entry to abdomen: Hemoperitoneum (~800 mL blood)
- Complete uterine rupture along prior incision site
- Fetal arm palpated through rupture site
- Baby partially extruded into abdomen
Delivery:
- Female infant delivered through uterine incision
- Limp, no spontaneous respirations initially
- Apgar: 2/5/7
Uterine Repair:
- 6 cm dehiscence of prior scar with extension into left broad ligament
- Active bleeding from uterine arteries
- Uterine repair performed in two layers
- Hemostasis achieved
- EBL: 1,800 mL
- Received 2 units PRBCs intraoperatively
Neonatal Outcome
- Female, 3,280 grams
- Cord gases: pH 6.95, base excess -16 (severe metabolic acidosis)
- Required PPV and brief chest compressions
- Intubated, NICU admission
- Therapeutic hypothermia initiated for HIE protocol
- Extubated day 3, MRI normal
- Discharged home day 10, following with neurology
Maternal Postoperative Course
- ICU monitoring for 24 hours
- Hemoglobin nadir 7.8, received additional 1 unit PRBCs
- Transitioned to floor POD 2
- Discharged POD 5
Counseling
- Future pregnancies: TOLAC contraindicated (prior rupture)
- Recommended cesarean delivery at 36-37 weeks in any future pregnancy
- Discussed recurrence risk and close monitoring if she becomes pregnant again
Clinical Image
Image Description: Intraoperative photograph demonstrating complete uterine rupture along a prior low transverse cesarean incision. The myometrial edges are separated with visible hemoperitoneum, and the fetus is partially visible through the defect.
Attribution: Educational illustration. Used for medical education purposes demonstrating uterine rupture recognition.