DOI: 10.1111/j.1471-0528.2010.02533.
x
www.bjog.org
Uterine rupture after previous caesarean section
I Al-Zirqi,a,b B Stray-Pedersen,a,b L Forsén,c S Vangenb
a
Faculty of Medicine, University of Oslo, Oslo, Norway b National Resource Centre for Women’s Health, Division of Obstetrics and
Gynaecology, Rikshospitalet, Oslo University Hospital, Oslo, Norway c Norwegian Institute of Public Health, Nydalen, Oslo, Norway
Correspondence: Dr I Al-Zirqi, Division of Obstetrics and Gynaecology, Rikshospitalet, Oslo University Hospital, Oslo 0027, Norway.
Email iqbal.al-zirqi@rikshospitalet.no
Accepted 29 January 2010. Published Online 24 March 2010.
Objective To determine the risk factors, percentage and maternal
and perinatal complications of uterine rupture after previous
caesarean section.
Design Population-based registry study.
Population Mothers with births ‡28 weeks of gestation after
previous caesarean section (n = 18 794), registered in the Medical
Birth Registry of Norway, from 1 January 1999 to 30 June 2005.
Methods Associations of uterine rupture with risk factors,
maternal and perinatal outcome were estimated using cross-
tabulations and logistic regression.
Main outcome measure Odds of uterine rupture.
Results A total of 94 uterine ruptures were identified (5.0/1000
mothers). Compared with elective prelabour caesarean section,
odds of rupture increased for emergency prelabour caesarean
section (OR: 8.63; 95% CI: 2.6–28.0), spontaneous labour
(OR: 6.65; 95% CI: 2.4–18.6) and induced labour (OR: 12.60;
95% CI: 4.4–36.4). The odds were increased for maternal age
‡40 years versus <30 years (OR: 2.48; 95% CI: 1.1–5.5),
non-Western (mothers born outside Europe, North America or
Please cite this paper as: Al-Zirqi I, Stray-Pedersen B, Forsén L, Vangen S. Uterine rupture after previous caesarean section. BJOG 2010;117:809–820.
Introduction
Uterine rupture is a rare peripartum complication associ-
ated with severe maternal and perinatal morbidity and
mortality,1,2 and is one of the most common clinical causes
of medical litigation in the developed world.3 Previous cae-
sarean section is the main risk factor for uterine rup-
ture.1,4–6 Because the rate of caesarean section is increasing
worldwide, we are dealing with an increasing number of
mothers with previous caesarean section, with consequent
higher risk of uterine rupture.7 The percentage of uterine
rupture after trial of labour (TOL) remains low (<1%),8
with usually favourable maternal and perinatal outcome.1,2
However, dramatic reduction of TOL9 has been observed
after reports of a worrying increase in rupture-related seri-
ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
Epidemiology
Australia) origin (OR: 2.87; 95% CI: 1.8–4.7) and gestational age
‡41 weeks versus 37–40 weeks (OR: 1.73; 95% CI: 1.1–2.7).
Uterine rupture after trial of labour significantly increased severe
postpartum haemorrhage (OR: 8.51; 95% CI: 4.6–15.1), general
anaesthesia exposure (OR: 14.20; 95% CI: 9.1–22.2),
hysterectomy (OR: 51.36; 95% CI: 13.6–193.4) and serious
perinatal outcome (OR: 24.51 (95% CI: 11.9–51.9). Induction by
prostaglandins significantly increased the odds for uterine
rupture compared with spontaneous labour (OR: 2.72; 95% CI:
1.6–4.7). Prelabour ruptures occurred after latent uterine activity
or abdominal pain in mothers with multiple or uncommon
uterine scars.
Conclusion Trial of labour carried greater risk and graver outcome
of uterine rupture than elective repeated caesarean section,
although absolute risks were low. A review of labour management
and induction protocol is needed.
Keywords Elective caesarean section, emergency prelabour
caesarean section, induced labour, maternal and perinatal
outcome, previous caesarean section, risk factors, spontaneous
labour, trial of labour, uterine rupture.
ous perinatal outcomes.10,11 This resulted in an increase in
the rate of caesarean section and associated short-term and
long-term complications.7,8 A meta-analysis found that
uterine rupture may be twice as common after TOL than
at elective repeat caesarean section.12 The majority of stud-
ies compared total TOL with elective repeated caesarean
section without looking specifically into ruptures at emer-
gency prelabour caesarean section, and without comparing
rupture rates after each of spontaneous and induced labour
with elective repeated caesarean section.
Norway has an increasing rate of caesarean section, from
1.8% in 1967 to 17.1% in 2008.13,14 However, there is a rel-
atively high rate of TOL with vaginal births in 51% of
mothers with previous caesarean section.15 This gives a
good basis for studying uterine rupture among mothers
809
 Al-Zirqi et al.
with different starts to birth after previous caesarean sec-
tion. Such information is available through the Medical
Birth Registry of Norway (MBRN) where data about all
births are routinely recorded.13
The aim of the present study was to determine the risk
factors, percentage and maternal and perinatal outcomes of
uterine rupture after previous caesarean section. A further
aim was to study the impact of different induction meth-
ods on uterine rupture and perinatal outcomes.
Methods
Design and study population
The study was a population-based registry study. We used
data from the MBRN. It is mandated by Norwegian law to
notify the MBRN of all births in Norway. Midwives or physi-
cians attending a birth complete a standardised form within
7 days of delivery. The form contains information on mater-
nal health before and during pregnancy, detailed information
about delivery and complications occurring intrapartum or
postpartum, and information about the newborn.
The target population of the present study was all mothers
giving birth from 1 January 1999 to 30 June 2005
(n = 365 107). This study sample comprised mothers with
previous caesarean section and subsequent births at gesta-
tional age ‡28 weeks. We excluded antepartum stillbirths,
and births with missing information on maternal age (n = 4),
parity (n = 19), gestational age (n = 56) and ethnic origin
(n = 161). The final sample included 18 794 mothers who
gave birth to a total of 19 057 infants. History of previous
caesarean section was specified in the MBRN data in a ticked
box without specifying the numbers of previous caesarean
sections. According to national guidelines, mothers attempt-
ing TOL should have only one previous caesarean section.16
We additionally performed a review of the medical
records of mothers with uterine rupture detected at prela-
bour caesarean section during the study period.
Variables
Main outcome measure
The main outcome measure was uterine rupture, coded as
‘yes’ or ‘no’. Uterine rupture was identified through diag-
nostic code ICD-10: O71.0 (uterine rupture prior to labour
start) and O71.1 (uterine rupture during labour) in the
registration form. The International Classification of Dis-
eases coding does not differentiate between complete or
incomplete uterine rupture.17
Explanatory variables
These included the following variables:
Start of birth categorised into: ‘Elective prelabour caesar-
ean section’ (reference), defined as planned caesarean sec-
810 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
tion performed before onset of labour, ‘Emergency
prelabour caesarean section’, defined as emergency caesar-
ean section before onset of labour, ‘Spontaneous labour
onset’, and ‘Induced labour onset’. Elective and emergency
prelabour caesarean section constituted prelabour caesarean
section, whereas spontaneous and induced labour consti-
tuted TOL. Definition of TOL was ‘an attempt of labour
that either resulted in vaginal birth after previous caesarean
section (VBAC), or resulted in emergency caesarean section
after labour start (failed VBAC). Information about start of
birth was complete.
Gestational age in weeks calculated by ultrasound at
18 weeks, categorised into: ‘24–36’, ‘37–40’ (reference), and
‘‡41’.
Demographic factors including Maternal age in years cate-
gorised into: ‘<30’ (reference), ‘30–39’, ‘‡40’; Parity cate-
gorised as ‘para 1’ (one previous delivery) (reference) and
‘para 2+’ (‡2 previous deliveries); Maternal ethnic origin,
categorised into ‘Western’ (reference) defined as: Europe,
North America and Australia, and ‘Non-Western’ defined
as outside Europe, North America and Australia.
Specific induction methods were categorised into: ‘Sponta-
neous labour onset’ (reference), induction by ‘Prostaglan-
dins with or without amniotomy’, ‘Prostaglandins,
amniotomy and oxytocin’, ‘Oxytocin with or without
amniotomy’, and ‘Mechanical methods’ defined as amniot-
omy alone or other non-medical induction methods.
In line with national guidelines,16 the prostaglandins
used were Prostin E2 (Dinoproston) intravaginal tablets
3 mg repeated after 6 hours if needed, with maximum dose
of three tablets. Oxytocin infusion consisted of 10 IU oxy-
tocin in 100 ml NaCl 9 mg/ml, using an IVAC infusion
pump, with a rate starting from 3 ml/hour when used for
induction, and from 1 ml/hour when used for augmenta-
tion. Infusion rate was increased by 3 ml/hour every
30 minutes if there was no established labour, with maxi-
mum infusion rate of 18 ml/hour, not exceeding 6 hours.
Fetal heart was monitored by cardiotocography (CTG) in
all mothers undergoing induction. The infusion was termi-
nated or reduced if contractions were well established. It
was also terminated if no contractions were established
within 8 hours from start of infusion.
All variables were identified in a ticked box on the birth
registration form.
Secondary outcome measures
Secondary outcome measures consisted of maternal and
perinatal outcomes.
Maternal outcomes
Severe postpartum haemorrhage, moderate postpartum
haemorrhage, hysterectomy, and exposure to general anaes-
thesia were secondary maternal outcome measures. Other

maternal outcomes such as postpartum sepsis, injuries to
other organs and maternal deaths were not detected after
uterine rupture, and were therefore not included.
Severe postpartum haemorrhage was defined as a visually
estimated blood loss of >1500 ml within 24 hours postpar-
tum, or the need for blood transfusion regardless of the
amount of blood loss, coded as ‘yes’ or ‘no’;
Moderate postpartum haemorrhage was defined as a visu-
ally estimated blood loss of 500–1500 ml within 24 hours
postpartum. Severe and moderate postpartum haemorrhage
and exposure to general anaesthesia were identified in a
tick box on the birth registration form.
Hysterectomy was identified through diagnostic coding
(The Nordic Medico-Statistical Committee Classification of
Surgical Procedures: LCD 00; LCC96; LCC00; MCA30;
MCA33).18 Information on maternal deaths was collected
from The Causes of Death Registry, Statistics Norway.
Perinatal outcome
Perinatal outcome was categorised into four mutually
exclusive groups:
Perinatal deaths defined as intrapartum fetal deaths
‡28 weeks of gestation, and neonatal deaths seven or more
days after birth, not related to congenital causes. Antepar-
tum stillbirths were excluded from the present study
because they were not delivery-related.
Post-hypoxic encephalopathy defined clinically as cerebral
irritation, cerebral depression or seizures in the presence of
severe asphyxia. Cerebral irritation was defined by national
consensus as a stage 1 encephalopathy, and cerebral depres-
sion as stage 2 encephalopathy as described by Sarnat and
Sarnat.19
Severe asphyxia efined by diagnostic coding ICD-10:
P21.0 (falling or steady pulse <100/minute at birth, absent
or gasping respiration, poor colour, absent tone; asphyxia
with 1-minute Apgar sore 0–3), without encephalopathy.
Other complications defined as any neonatal problem
with or without admission to neonatal intensive care unit,
excluding perinatal deaths, severe asphyxia and post-hyp-
oxic encephalopathy (PHE) described above. Common
problems included prematurity, moderate and non-specific
asphyxia, hypoglycaemia, respiratory distress syndrome and
transient tachypnoea of the newborn.
Serious perinatal outcome was a computed variable,
defined as a composite of perinatal deaths, severe asphyxia
and PHE.
Statistical analysis
Frequency analysis was used to quantify the percentage of
uterine rupture among all mothers with previous caesarean
section, and among mothers with different starts of birth.
The association of uterine rupture with different starts of
birth, demographics and obstetric risk factors was analysed
ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
Uterine rupture
using cross-tabulation and logistic regression. All explana-
tory variables with a significance level of P £ 0.20 in bivari-
ate analyses were included in the multivariate analysis. The
association between uterine rupture and maternal and peri-
natal outcomes was assessed using cross-tabulations and
bivariate logistic regression models at different starts of
birth. Fisher’s exact test was used when the outcome mea-
sure was of insufficient sample size. A multiple logistic
regression model was used to measure the association of
induction methods with uterine rupture risk among moth-
ers attempting TOL. The association of induction of labour
with perinatal outcomes was measured using cross-tabula-
tions and multiple logistic regressions. The level of signifi-
cance in multivariate analysis was set at P < 0.05 and the
data were analysed using SPSS, version 15 (Chicago, IL,
USA). The influence of observations on the fit of the model
was tested for each coefficient in the final models by using
the influence test DfBeta in the logistic regression in SPSS.20
Results
A total of 11 954 mothers of 18 794 with previous caesar-
ean section attempted TOL, giving TOL rate of 63.6%,
whereas 6840 had prelabour caesarean section (36.4%)
(Figure 1). There were 94 uterine ruptures detected among
18 794 mothers (5/1000). Ruptures were identified in 80
mothers after TOL and in 14 mothers with prelabour cae-
sarean sections. Although the percentage of uterine rupture
was lowest for elective prelabour caesarean section (0.7/
1000), it was much higher when prelabour caesarean sec-
tion was an unplanned emergency section (7.1/1000). Rup-
tures were significantly higher after TOL compared with
prelabour caesarean section (6.7/1000 versus 2.0/1000;
P = 0.000). Failed VBACs were associated with the highest
rupture rates. Trial of labour resulted in 80.1% VBACs and
19.9% failed VBACs. Failed VBAC was significantly more
likely after induced labour than spontaneous labour
(Figure 1, Table 1). Vaginal births complicated by ruptures
were five spontaneous vaginal and five vacuum deliveries.
Risk factors of uterine rupture
Start of birth was a significant risk factor for uterine rup-
ture. Compared with elective prelabour caesarean section,
the odds of rupture were highest for induction (OR: 12.6;
95% CI: 4.4–36.4), followed by emergency prelabour cae-
sarean section (OR: 8.6; 95% CI: 2.6–28.0) and spontane-
ous labour (OR: 6.6; 95% CI: 2.4–18.6) (Table 1).
Trial of labour (spontaneous and induced labour) signif-
icantly increased the odds for uterine rupture versus elec-
tive caesarean section (OR: 7.96; 95% CI: 2.9–22.0) (data
not shown in table). Although a maternal age ‡40 years
versus <30 years was not a significant risk factor in bivari-
ate analysis, it significantly doubled the odds for rupture in
811
 Al-Zirqi et al.

Total pregnant population

(1999–2005)
n = 365 107

Mothers with previous CS

n = 18 794

Prelabour CS Trial of labour

n = 6840 (36.4) n = 11 954 (63.6)

Elective CS Emergency CS Spontaneous onset Induced onset

n = 5442 (79.6) n = 1398 (20.4) n = 9239 (77.3) n = 2715 (22.7)

VBAC Failed VBAC VBAC Failed VBAC

n = 7555 (81.8) n = 1684 (18.2) n = 2018 (74.3) n = 697 (25.7)

Uterine rupture Uterine rupture Uterine rupture Uterine rupture

n = 8 (0.1) n = 43 (2.6) n = 2 (0.1) n = 27 (3.9)

Uterine rupture Uterine rupture Uterine rupture Uterine rupture

n = 4 (0.07) n = 10 (0.7) n = 51 (0.6) n = 29 (1.1)

Uterine rupture Uterine rupture

n = 14 (0.2) n = 80 (0.7)

Uterine rupture
n = 94 (0.5)

Figure 1. Uterine rupture (n, %) at prelabour caesarean section (CS) and at trial of labour among mothers with previous CS.

multivariate analysis after adjusting for start of birth. The
odds of rupture at older age became even greater after
excluding mothers with prelabour caesarean sections. Non-
Western maternal origin doubled rupture odds compared
with maternal Western origin. Gestational age ‡41 weeks
versus 37–40 weeks significantly increased the odds for
uterine rupture, but this increase was marginal in multivar-
iate analysis after adjusting for start of birth. Parity ‡2
showed a protective effect against uterine rupture, espe-
cially in the TOL group where the risk was halved, indicat-
ing a protective effect of previous vaginal delivery. There
was no major influence of single individuals on the esti-
mated coefficients after using the influence test DfBeta.
Ruptures at prelabour caesarean section
Clinical details of 11 of 14 mothers with ruptures at prela-
bour caesarean section were available and are shown in
Table 2. All infants were inside the uterine cavity. Three
mothers had elective caesarean sections, revealing complete
rupture without any contractions or CTG changes. Eight
mothers had emergency prelabour caesarean sections after
infrequent contractions and/or abdominal pain, revealing
five complete ruptures and three dehiscences. CTG changes
were observed in only two mothers, and both had complete
ruptures. Low vertical uterine scars or transverse scars in the
lower part of the corpus were present in five mothers; one
of the five mothers had had previous complete rupture of
an inverted T scar following spontaneous contractions at
37 weeks; she presented in the index pregnancy with prela-
bour dehiscence at 28 weeks. Multiple uterine scars were
present in eight mothers, and two presented with acute
abdomen revealing complete ruptures of myomectomy
scars. All but two neonates had Apgar scores ‡7 at 1 minute.
Severe postpartum haemorrhage occurred in one mother.
Maternal outcome after uterine rupture
Uterine ruptures among all mothers with previous caesar-
ean section resulted in a three-fold, seven-fold, ten-fold
and 23-fold increased risk of moderate postpartum haem-
orrhage, severe postpartum haemorrhage, general anaesthe-
sia exposure and peripartum hysterectomy, respectively
(Table 3). The increase in the odds of these morbidities
was significant only if ruptures occurred after TOL
(Table 3). However, no maternal death, injuries to other
organs or postpartum sepsis was identified. Almost half of
the mothers diagnosed with uterine rupture after TOL,
developed moderate postpartum haemorrhage and almost
half were exposed to general anaesthesia, while 15% devel-
oped severe postpartum haemorrhage and 3.8% needed
peripartum hysterectomy.
Perinatal outcomes after uterine rupture
Among 19 057 births, 97 were complicated by uterine rup-
tures (81 after TOL and 16 at prelabour caesarean section).

812 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
 Uterine rupture

Table 1. Risk factors for uterine rupture among mothers with previous caesarean section

Total no. Uterine rupture, Unadjusted Adjusted OR*

n (no./1000) OR (95% CI) (95% CI)

Total 18 794 94 (5.0)

Start of birth
Prelabour caesarean section 6840 14 (2.0)
Elective prelabour caesarean section (ref.) 5442 4 (0.7) 1 1
Emergency prelabour caesarean section 1398 10 (7.1) 9.79 (3.1–31.2) 8.63 (2.6–28.0)
Trial of labour 11 954 80 (6.7)
Spontaneous labour onset 9239 51 (5.5) 7.54 (2.7–20.9) 6.65 (2.4–18.6)
Induced labour onset 2715 29 (10.7) 14.67 (5.2–41.8) 12.60 (4.4–36.4)
Maternal age in years
<30 13 608 66 (4.8) 1 1
30–39 (ref.) 4339 21 (4.8) 0.99 (0.6–1.6) 1.19 (0.7–1.9)
‡40 847 7 (8.3) 1.71 (0.6–7.6) 2.48 (1.1–5.5)**
Ethnic origin
Western (ref.) 16 862 72 (4.3) 1 1
Non-Western 1932 22 (11.4) 2.68 (1.7–4.3) 2.87 (1.8–4.7)
Parity
1 (ref.) 10317 63 (6.1) 1 1
‡2 8477 31 (3.6) 0.59 (0.4–0.9) 0.61 (0.4–0.9)***
Gestational age in weeks
28–36 1704 9 (5.3) 1.34 (0.7–2.7) 1.10 (0.5–2.3)
37–40 (ref.) 13996 55 (3.9) 1 1
‡41 3094 30 (9.7) 2.48 (1.6–3.9) 1.73 (1.1–2.7)

OR, odds ratio; 95% CI, 95% confidence intervals.

*Adjusted for all variables in table.
**Analysing only mother attempting trial of labour: OR: 3.02; 95% CI: 1.3–7.2.
***Analysing only mother attempting trial of labour: OR: 0.47; 95% CI: 0.3–0.8.

All were single births except for two sets of twins, delivered
by prelabour caesarean sections, and one twin set after
TOL. Uterine ruptures resulted in 56 neonates with perina-
tal complications (0.29% of total births), of which nine
were serious (Table 4). There were no deaths later than
7 days following ruptures. Uterine rupture resulted in a sig-
nificantly larger number of perinatal complications when it
occurred after TOL. Perinatal complications occurred in 48
neonates out of 81 ruptures after TOLs (59.3%).
One intrapartum death followed rupture and placental
abruption after induction by prostaglandins at 40 weeks of
gestation. The other resulted after inverted T scar rupture at
37 weeks following spontaneous contractions. Early neonatal
death occurred on the second day following uterine rupture
after spontaneous labour, augmented by oxytocin, at
41 weeks of gestation. All three were delivered by emergency
caesarean section because of threatened fetal hypoxia. Neo-
nates with PHE comprised one born after spontaneous
labour at 41 weeks, and two born at term after induction
with prostaglandins. Two were delivered by emergency cae-
sarean section and one by vacuum extraction because of
threatened fetal hypoxia. Neonates with severe asphyxia
without encephalopathy were delivered at term by emergency
caesarean section because of threatened fetal hypoxia. These
comprised one after spontaneous labour, one after induction
with prostaglandins and one after mechanical induction.
In contrast, ruptures at elective or emergency prelabour
caesarean sections had no significant impact on perinatal
outcome. These ruptures resulted in eight neonates with
minimal complications, mainly because of prematurity and
respiratory distress syndrome.
The impact of induction method
Among mothers attempting TOL, induction significantly
increased the odds for uterine rupture versus spontaneous
labour, only when using prostaglandins with or without
amniotomy (OR: 2.7). Induction by mechanical methods
resulted in a rupture rate similar to the rate after spontane-
ous labour and lower than the rupture rate after prosta-
glandins (Table 5).
Compared with spontaneous labour without rupture,
uterine ruptures after induction increased the odds for seri-
ous perinatal outcomes by 41-fold, whereas ruptures after
spontaneous labour increased the odds by 15-fold.

ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 813
 Al-Zirqi et al.

Table 2. Characteristics of births in 11 mothers with uterine ruptures at prelabour caesarean section

Obstetric history Clinical presentation Operative finding Outcome

Mother 1 Para 2; two previous CS; first at
25 weeks (vertical uterine
incision); second at 33 weeks
(low transverse incision)
Mother 2 Para 1; previous CS at 28 weeks
(vertical uterine incision)
Mother 3 Para 2; two previous CS; second
at term, through transverse
incision in lower part of corpus
due to adhesions.
Mother 4 Para 3; first: vaginal delivery;
second: emergency CS at
29 weeks (inverted T incision);
thrid: rupture of scar at
37 weeks after contractions,
resulting in stillbirth
Mother 5 Para 4; four previous CSs at
term.
Mother 6 Para 1; previous CS at term due
to prolonged labour
Mother 7 Para 1; previous CS at term due
to prolonged labour
Mother 8 Para 1; previous CS; previous
laparoscopic myomectomy
Mother 9 Para 2; two previous CS; one at
26 weeks (vertical incision)
Mother 10 Para 2; two previous CS due to
prolonged labour
Mother 11 Para 1; previous CS; previous
laparoscopic myomectomy on
posterior uterine wall.
38 weeks; no contractions;
normal CTG; elective CS
38 weeks; no contractions;
normal CTG; elective CS
38 weeks; twin pregnancy; no
contractions; normal CTG;
elective CS
28 weeks; infrequent
contractions; normal CTG;
ultrasound showed uterine wall
could not be seen; emergency
prelabour CS
33 weeks; twin pregnancy;
constant pain and tenderness
on uterus; normal CTG;
ultrasound showed thin
isthmus; emergency prelabour
CS
41 weeks; infrequent
contractions; borderline CTG;
emergency prelabour CS
38 weeks; infrequent
contractions; normal CTG;
emergency prelabour CS
37 weeks; acute abdomen; no
contractions; normal CTG;
emergency prelabour CS
36 weeks; infrequent
contractions; emergency
prelabour CS
38 weeks; infrequent
contractions; borderline CTG;
emergency prelabour CS
35 weeks; constant pain and
tenderness on uterus; normal
CTG; emergency prelabour CS
Complete rupture of transverse 1 minute AS ‡7
lower segment scar; intact
amniotic membranes
Small complete rupture in 1 minute AS ‡7
uterine fundus; intact amniotic
membranes
Complete rupture of upper scar; 1 minute AS ‡7
intact amniotic membrane
Dehiscence: absence of muscles Severe maternal
in isthmus and vertical midline PPH
up to fundus; infant parts 1 minute AS ‡7
palpated under a fibrous
membrane
Dehiscence (lower segment scar). 1 minute AS ‡7
Infant seen moving under
transparent serosa
Complete rupture (lower 1 minute AS ‡7
segment scar); intact amniotic
membranes
Complete rupture (lower 1 minute AS ‡7
segment scar); placenta
protruding through rupture
Complete rupture in uterine 1 minute AS ‡7
fundus; amniotic fluid filling
peritoneal cavity
Dehiscence (transverse lower 1 minute AS 4;
segment scar); infant seen 5 minute AS ‡7
moving under transparent
serosa
Complete rupture (lower 1 minute AS ‡7
segment scar); amniotic
membranes: not intact
Complete scar rupture on 1 minute AS 3;
posterior uterine wall; amniotic 5 minute AS ‡7
membrane: not intact

AS, Apgar score; CS, caesarean section; CTG, cardiotocograph; PPH, postpartum haemorrhage.

pain in mothers with multiple or uncommon uterine scars.

Discussion
Main results
Uterine rupture occurred in 5/1000 mothers with previous
caesarean section. Trial of labour, especially after induction
using prostaglandins, significantly increased the odds for
uterine rupture compared with elective prelabour caesarean
section. Ruptures at emergency prelabour caesarean section
occurred mostly after latent uterine activity or abdominal
Ruptures occurring after TOL were associated with signifi-
cantly higher odds for severe maternal morbidity and serious
perinatal outcomes. The greatest odds for serious perinatal
outcomes followed ruptures after induction of labour.
Strengths and weaknesses of the study
The strength of this study was the population-based design,
covering a large sample, allowing analysis of a rare compli-

814 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
 Uterine rupture

Table 3. Maternal outcomes after uterine ruptures at different starts of birth following previous caesarean section (n = 18 794 mothers)*

Start of birth Severe postpartum Moderate postpartum Hysterectomy General anaesthesia

haemorrhage haemorrhage (500–
(>1500 ml blood loss) 1500 ml blood loss)

n (%) OR n (%) OR n (%) OR n (%) OR

(95% CI) (95% CI) (95% CI) (95% CI)

Elective prelabour 115 (2.1) 1144 (26.5) 11 (0.2) 377 (6.9)

CS (n = 5442)
No rupture (ref.) (n = 5438) 115 (2.1) 1 1143 (26.5) 1 11 (0.2) 1 377 (6.9) 1
Rupture (n = 4) 0 (0.0) NA 1 (25.0) 0.92 0 (0.0) NA 0 (0.0) NA
(0.1–8.9)
Emergency prelabour 52 (3.7) 351 (25.1) 6 (0.4) 250 (17.9)
CS (n = 1398)
No rupture (ref.) (n = 1388) 51 (3.7) 1 350 (25.2) 1 6 (0.4) 1 246 (17.7) 1
Rupture (n = 10) 1 (10.0) 2.90 1 (10.0) 0.33 0 (0.0) NA 4 (40.0) 3.09
(0.4–23.4) (0.04–2.6) (0.8–11.8)
Trial of labour** 253 (2.1) 2098 (17.6) 12 (0.1) 749 (6.3)
(n = 11 954)
No rupture (ref.) (n = 11 874) 241 (2.0) 1 2059 (17.3) 1 9 (0.1) 1 711 (6.0) 1
Rupture (n = 80) 12 (15.0) 8.51 39 (48.8) 4.53 3 (3.8) 51.36 38 (47.5) 14.20
(4.6–15.1) (2.9–7.0) (13.6–193.4) (9.1–22.2)
All mothers (n = 18 794) 420 (2.2) 3893 (20.7) 29 (0.2) 1376 (7.3)
No rupture (ref.) (n = 18 700) 407 (2.2) 1 3852 (20.7) 1 26 (0.1) 1 1334 (7.1) 1
Rupture (n = 94) 13 (13.8) 7.21 41 (43.6) 2.98 3 (3.2) 23.67 42 (44.7) 10.51
(3.9–13.0) (1.9–4.5) (4.0–79.6) (6.9–15.8)

CS, caesarean section; NA, not applicable; OR, odds ratio; 95% CI, 95% confidence intervals.
*No injuries to other organ, postpartum sepsis or maternal deaths detected following uterine ruptures.
**Spontaneous and induced labour.

cation like uterine rupture. We included all births after
previous caesarean section regardless of the size of the
maternity unit so a selection bias due to unit resources was
avoided.
The weaknesses of this study include the use of ICD cod-
ing not distinguishing between complete and incomplete
uterine rupture. However, we performed a small validation
study of coding practice of intrapartum ruptures during the
year 2003 in Oslo University Hospital. We found three com-
plete and nine incomplete ruptures. The diagnostic codes
O71.0 or O71.1, used to identify uterine ruptures in the
MBRN file, had only been given to the three complete rup-
tures; the nine dehiscences were coded Z03.8 (threatened
uterine rupture), which was not used to identify ruptures in
the data file. Moreover, the percentage of uterine rupture in
this study, especially after TOL, was similar to percentages
reported for complete uterine ruptures in other studies.21,22
The worse maternal and perinatal outcomes after these rup-
tures indicate that they were probably complete ruptures.
As a result of the small number of events (ruptures),
some of the results were associated with wide confidence
intervals. However, meta-analyses may achieve higher preci-
sion.21–24
The impact of start of birth on uterine rupture
The overall percentage of uterine rupture of 0.5% in moth-
ers with previous caesarean section was low, similar to that
reported in previous studies in the developed world.8,23
Our rupture percentage of 0.7% after TOL was under 1%,
in agreement with previous reports.22,23 Although TOL
increased the odds of uterine rupture eight-fold compared
with elective prelabour caesarean section, the absolute
number was low. The percentage of rupture of 1.1% after
induced labour lies within the range reported earlier
between 0.3%25 and 4.6%.26 The low rupture rate at elec-
tive prelabour caesarean section (0.07%) was consistent
with that of 0.16% reported in a meta-analysis.12 The sig-
nificant increase of ruptures at failed VBACs indicates the
importance of careful selection of mothers for TOL, and
optimising labour management.
Obstetric history and ruptures at prelabour
caesarean section
Complete uterine ruptures were detected at elective caesar-
ean sections in two mothers with low vertical uterine scars
and one with a transverse scar in the lower corpus. This
indicates that the type of scar plays a role in prelabour

ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 815
816
Al-Zirqi et al.

Table 4. Perinatal outcomes after uterine ruptures at different starts of birth following previous caesarean section (n = 19 057 births)

Start of Serious Serious perinatal outcomes Other perinatal Total perinatal

birth perinatal complications complications
outcomes Perinatal death Severe asphyxia Post-hypoxic
encephalopathy

n (%) P n (%) P n (%) P n (%) P n (%) P n (%) P

Elective prelabour CS 5 (0.1) 0 (0.0) 5 (0.1) 0 (0.0) 2033 (36.6) 2038 (36.7)
(n = 5555)
No rupture (ref.) 5 (0.1) 0 (0.0) 5 (0.1) 0 (0.0) 2029 (36.6) 2034 (36.6)
(n = 5550)
Rupture (n = 5) 0 (0.0) 1.000 0 (0.0) NA 0 (0.0) 1.000 0 (0.0) 0.063 4 (80.0) 0.063 4 (80.0) 0.064
Emergency prelabour CS 17 (1.2) 6 (0.4) 9 (0.6) 2 (0.1) 771 (53.2) 788 (54.3)
(n = 1450)
No rupture (ref.) (n = 1439) 17 (1.2) 6 (0.4) 9 (0.6) 2 (0.1) 767 (53.3) 784 (54.5)
Rupture (n = 11) 0 (0.0) 1.000 0 (0.0) 1.000 0 (0.0) 1.000 0 (0.0) 1.000 4 (36.4) 0.262 4 (36.4) 0.241
Trial of labour (n = 12 052) 69 (0.6) 17 (0.1) 38 (0.3) 14 (0.1) 4544 (37.7) 4613 (38.3)
No rupture (ref.) (n = 11 971) 60 (0.5) 14 (0.1) 35 (0.3) 11 (0.1) 4505 (37.6) 4565 (38.1)
Rupture (n = 81) 9 (11.1) 0.000* 3 (3.7) 0.000 3 (3.7) 0.002 3 (3.7) 0.000 39 (48.1) 0.052 48 (59.3) 0.000
All births (n = 19 057) 91 (0.5) 23 (0.1) 52 (0.3) 16 (0.1) 7348 (38.6) 7439 (39.0)
No rupture (ref.) (n = 18 960) 82 (0.4) 20 (0.1) 49 (0.3) 13 (0.1) 7301 (38.5) 7383 (38.9)
Rupture (n = 97) 9 (9.3) 0.000 3 (3.1) 0.000 3 (3.1) 0.002 3 (3.1) 0.000 47 (48.5) 0.045 56 (57.7) 0.000

NA, not applicable.

*Odds ratio: 24.51 (95% confidence interval: 11.9–51.9).

ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
 Uterine rupture

Table 5. Association of induction of labour with uterine rupture and perinatal outcomes after previous caesarean section

Total no. Uterine rupture OR (95% CI) OR** (95% CI)

(mothers)* no. (per 1000)

Total 11 954 80 (6.6)

Spontaneous labour onset (ref.) 9239 51 (5.5) 1 1
Induction methods 2715 29 (10.7)
Prostaglandins +/) amniotomy 1130 18 (15.9) 2.91 (1.7–5.0)*** 2.72 (1.6–4.7)
Prostaglandins, amniotomy and oxytocin 168 2 (11.9) 1.30 (0.5–3.6) 1.22 (0.4–3.4)
Oxytocin +/) amniotomy 555 4 (7.2) 2.17 (0.5–8.9) 2.01 (0.5–8.3)
Mechanical methods 862 5 (5.8) 1.05 (0.4–2.6)*** 1.04 (0.4–2.6)

Total no. Serious perinatal OR (95% CI) OR** (95% CI)

(births) outcome no. (%)

Total 12 052 69 (0.6)

Spontaneous labour, no rupture (ref.) 9259 45 (0.5) 1 1
Spontaneous labour, rupture 52 4 (7.7) 17.06 (5.9–49.3) 15.40 (5.3–44.8)
Induced labour, no rupture 2712 15 (0.6) 1.13 (0.6–2.0) 1.08 (0.6–1.9)
Induced labour, rupture 29 5 (17.2) 42.65 (15.6–116.8) 41.77 (15.1–115.8)

OR, odds ratio; 95% CI, 95% confidence interval.

No major influence of single individuals on the estimated coefficients was found in the model after using the influence test DfBeta.
*Mothers attempting trial of labour.
**Adjusted for gestational age.
***Prostaglandins versus mechanical method: (OR: 2.75: 95% CI: 1.1–7.4).

ruptures.27,28 We propose that mothers with these scars
should be scheduled for elective caesarean section not later
than 38 weeks. However, one should be aware that the risk
of iatrogenic prematurity and respiratory problems would
be increased in infants born by caesarean sections at earlier
gestations; a balance between uterine rupture and prematu-
rity risk should be assessed for each individual pregnancy.
The high percentage of ruptures identified at emergency
prelabour caesarean section in this study has not been
addressed previously. The majority of these mothers had
multiple uterine scars or other risk factors in their obstetric
history. With the exception of two borderline CTGs, there
were no other abnormal CTG changes. This indicates that
mothers presenting with infrequent contractions and normal
CTG should not be left without quick intervention if they
had either multiple uterine scars, vertical scars, previous
uterine ruptures or myomectomy scars.29 Ultrasound evalu-
ation of lower segment thickness in the third trimester might
help to prevent such ruptures.30 The prelabour dehiscences
and ruptures could have resulted in catastrophic outcomes if
mothers had been left longer without intervention.
samples, found an increased rupture risk for gestational age
beyond term, possibly as result of decreased thickness of
the lower uterine segment as the pregnancy progresses.31–34
Other studies of larger samples, showed that advanced ges-
tational age was not a significant risk factor.35 In this study
there was a significant risk associated with advanced gesta-
tional age, but this was mostly related to the higher induc-
tion rate at this gestational age. A maternal age ‡40 years
was associated with increased risk of uterine rupture, a
finding in accordance with previous studies.33,36 Many fac-
tors may contribute to the increased uterine rupture at
older age, including increasing dysfunctional labour
because of decreasing strength of the myometrium, and
defective healing of the uterine scar.37 Mothers of non-
Western origin had increased risk of uterine rupture, in
keeping with previous studies indicating greater risk of
maternal and perinatal morbidity and mortality in these
mothers.38 Communication problems and missing informa-
tion on obstetric history might play a role in this regard.
Finally, the protective effect of previous vaginal delivery is
in agreement with previous studies.21,39

The impact of gestational age, maternal age
and ethnic origin
There is a controversy regarding the role of advanced gesta-
tional age in increasing rupture risk among mothers with
previous caesarean section. Earlier studies, mostly of small
The impact of uterine rupture on outcome
The minimal maternal morbidity after uterine ruptures at
prelabour caesarean section, in contrast to ruptures after
TOL, indicates the significant risks of labour after previ-
ous caesarean section. The absence of maternal death,

ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology 817
 Al-Zirqi et al.
injuries to other organs, and postpartum sepsis may be
related to prompt diagnosis and management in hospital
settings.
The significant impact of uterine rupture after TOL on
perinatal outcomes was similar to other studies,23,24 reflect-
ing the serious nature of such ruptures, even in hospital
settings. However, the absolute numbers of serious perina-
tal outcomes were relatively low.
The lack of significant impact of ruptures at prelabour
caesarean section may indicate a shorter duration of fetal
hypoxia versus ruptures after TOL, a less catastrophic nat-
ure in the absence of strong contractions, or that unneces-
sary delay in delivering the infant was avoided.40
The impact of induction
Induction of labour, especially with prostaglandins,
increased the risk of uterine rupture in this sample as dem-
onstrated elsewhere.26,33,41–46 Buhimschi et al.46 found that
women induced with prostaglandins were more likely to
rupture at the site of the uterine scar than those induced
with oxytocin, suggesting that prostaglandins could induce
local, biochemical modifications that weaken the scar, pre-
disposing to rupture. Amniotomy and other mechanical
methods carried lower risk of rupture than prostaglandin.
This might reflect the strategy of using prostaglandins for
an unripe cervix, whereas mechanical methods and oxytocin
are used when the cervix is riper, resulting in shorter dura-
tion of induction. According to our protocol of induction,
we were using a relatively higher dose of prostaglandins and
oxytocin compared with other countries with a stricter pro-
tocol.25 The results suggest a need to review our induction
protocol. Mechanical methods such as intracervical Foley
catheter for preinduction ripening might offer safer induc-
tion. 47 Induction, especially with prostaglandins, should be
used with extreme caution among mothers with previous
caesarean section.39,48–50 Larger, ideally prospective, studies
with information on dose and type of induction agent,
duration of labour and underlying risk factors are needed.
Conclusion
Among mothers with previous caesarean section, TOL,
especially after induction, had a significantly increased risk
for uterine rupture compared with elective prelabour cae-
sarean section. Ruptures occurred even with latent uterine
activity, particularly in women with multiple or uncom-
mon uterine scars. Uterine ruptures were significantly asso-
ciated with severe maternal morbidity and serious perinatal
outcome when occurring after trial of labour. Not recom-
mending trial of labour to mothers with higher risk for
failed attempt at VBAC might reduce the rate of uterine
rupture. A review of induction protocols is needed to
reduce uterine rupture risk and associated serious perinatal
818 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
outcome. Further studies covering a larger sample over a
longer interval of time are highly recommended.
Disclosure of interest
None declared.
Contribution to authorship
IA designed the study and wrote the paper. SV and BS
contributed to the study design and drafting, revising it
critically and approving the final article draft. LF helped in
statistical analyses, interpretation of the results and produc-
ing the tables.
Details of ethics approval
The Regional Ethical Committee for Medical Research, the
Norwegian Data Inspectorate and the Norwegian Director-
ate of Health approved the study.
Funding
We would like to thank the Norwegian Foundation for
Health and Rehabilitation and the Norwegian Women’s
Public Health Association for funding the study.
Acknowledgements
Special thanks are due to Pernille Frese, from the National
Resource Centre for Women’s Health in Rikshospitalet for
her help in drawing the figure provided. We are also grate-
ful to our Consultant colleagues for their great effort in
compiling the clinical details from case records of mothers
with uterine ruptures in their respective departments: Dr
Anne Flem Jacobson from Ullevål hospital, Oslo University
Hospital, and Dr Per E Børdahl from Haukeland Hospital,
Bergen. j
References
1 Ofir K, Sheiner E, Levy A, Katz M, Mazor M. Uterine rupture: risk
factors and pregnancy outcome. Am J Obstet Gynecol
2003;189:1042–6.
2 Yap OW, Kim ES, Laros RK Jr. Maternal and neonatal outcomes
after uterine rupture in labor. Am J Obstet Gynecol 2001;184:1576–
81.
3 Mavroforou A, Koumantakis E, Michalodimitrakis E. Physicians’ liabil-
ity in obstetric and gynecology practice. Med Law 2005;24:1–9.
4 Murphy DJ. Uterine rupture. Curr Opin Obstet Gynecol
2006;18:135–40.
5 Taylor LK, Simpson JM, Roberts CL, Olive EC, Henderson-Smart DJ.
Risk of complications in a second pregnancy following caesarean
section in the first pregnancy: a population-based study. Med J Aust
2005;183:515–9.
6 Smith JG, Mertz HL, Merrill DC. Identifying risk factors for uterine
rupture. Clin Perinatol 2008;35:85–99.
7 Zelop C, Heffner LJ. The downside of cesarean delivery: short- and
long-term complications. Clin Obstet Gynecol 2004;47:386–93.
8 Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan BKS, Helfand
M. Systematic review of the incidence and consequences of uterine

rupture in women with previous caesarean section. BMJ
2004;329:19–25.
9 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmey-
er S, et al. Births: final data for 2006. National vital statistics reports;
vol 57 no 7. Hyattsville, MD: National Center for Health Statistics
2009 [www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_07.pdf]. Accessed
16 November 2009.
10 Jones RO, Nagashima AW, Hartnet-Goodman MM, Goodlin RC.
Rupture of low transverse cesarean scars during trial of labor. Obstet
Gynecol 1991;77:815–7.
11 Scott JR. Mandatory trial of labor after cesarean delivery: an alterna-
tive viewpoint. Obstet Gynecol 1991;77:811–4.
12 Mozurkewich EL, Hutton EK. Elective repeat cesarean delivery versus
trial of labor: a meta-analysis of the literature from 1989–1999.
Am J Obstet Gynecol 2000;183:1187–97.
13 Irgens LM. The Medical Birth Registry of Norway. Epidemiological
research and surveillance throughout 30 years. Acta Obstet Gynecol
Scand 2000;79:435–9.
14 Medical Birth Registry of Norway. [mfr-nesstar.uib.no/mfr/]. Accessed
16 November 2009.
15 Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Effects of onset
of labor and mode of delivery on severe postpartum hemorrhage.
Am J Obstet Gynecol 2009;201:273.
16 The Norwegian Society of Gynaecology and Obstetrics. Guidelines in
Obstetrics. Oslo, Norway: The Norwegian Medical Association, 2006.
17 Directorate of Health and Social Services. The international statistical
classification of diseases and related health problems, ICD-10, 10th
revision. Used With Permission From WHO. Norwegian edition.
Geneva: World Health Organization, 2005.
18 Directorate of Health and Social Services. The Classification of
Medical and Surgical Procedures. Used With Permission From the
NOMESCO Classification of Surgical Procedures. Norwegian edition.
Copenhagen: NOMESCO, 2006.
19 Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal dis-
tress: a clinical and encephalography study. Arch Neurol 1976;33:
696–705.
20 Skrondal A, Rabe-Hesketh S. Generalized Latent Variable Modelling:
Multilevel, Longitudinal, and Structural Equation Models. Boca
Raton, FL: Chapman & Hall/CRC interdisciplinary statistics series.
2004. pp. 278–9.
21 Macones GA, Peipert J, Nelson DB, Odibo A, Stevens EJ, Stamilio
DM, et al. Maternal complications with vaginal birth after cesarean
delivery: a multicenter study. Am J Obstet Gynecol 2005;193:
1656–62.
22 Spong CY, Landon MB, Gilbert S, Rouse DJ, Leveno KJ, Varner MW,
et al. Risk of uterine rupture and adverse perinatal outcome at term
after cesarean delivery. Obstet Gynecol 2007;110:801–7.
23 Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner
MW, et al. Maternal and perinatal outcomes associated with a trial of
labor after prior cesarean delivery. N Engl J Med 2004;351:2581–9.
24 Smith GCS, Pell JP, Cameron AD, Dobbie R. Risk of perinatal death
associated with labor after previous cesarean delivery in uncompli-
cated term pregnancies. JAMA 2002;287:2684–90.
25 Locatelli A, Chidini A, Ciriello E, Incerti M, Bonardi C, Regalia AL.
Induction of labor: comparison of a cohort with uterine scar from
previous cesarean section vs. a cohort with intact uterus. J Matern
Fetal Neonatal Med 2006;19:471–5.
26 Ravasia DJ, Wood SL, Pollard JK. Uterine rupture during induced trial
of labor among women with previous cesarean delivery. Am J
Obstet Gynecol 2000;183:1176–9.
27 American College of Obstetricians and Gynecologists. Vaginal birth
after previous cesarean section. ACOG Practice Bulletin 54. Wash-
ington, DC: ACOG; 2004.
ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology
Uterine rupture
28 Rochelson B, Pagano M, Conetta L, Goldman B, Vohra N, Frey M,
et al. Previous preterm cesarean delivery: identification of a new risk
factor for uterine rupture in VBAC candidates. J Matern Fetal Neo-
natal Med 2005;18:339–42.
29 Pelosi MA III, Pelosi MA. Spontaneous uterine rupture at thirty-three
weeks subsequent to previous superficial laparascopic myomectomy.
Am J Obstet Gynecol 1997;177:e1547–9.
30 Bujold E, Jastrow N, Simoneau J, Burnet S, Gauthier RJ. Prediction of
complete uterine rupture by sonographic evaluation of the lower
uterine segment. Am J Obstet Gynecol 2009;201:e1–6.
31 Usha Kiran TS, Chui YK, Bethel J, Bhal PS. Is gestational age an
independent variable affecting uterine scar rupture rates? Eur J
Obstet Gynecol Reprod Biol 2006;126:68–71.
32 Hammoud A, Hendler I, Gauthier RJ, Berman S, Sansregret A, Bujold
E. The effect of gestational age on trial of labor after caesarean sec-
tion. J Matern Fetal Neonatal Med 2004;15:202–6.
33 Kaczmarczyk M, Sparen P, Terry P, Cnattingius S. Risk factors for
uterine rupture and neonatal consequences of uterine rupture. A
population- based study of successive pregnancies in Sweden. BJOG
2007;114:1208–14.
34 Gotoh H, Masuzaki H, Yoshida A, Yoshimura S, Miyamura T,
Ishimaru T. Predicting incomplete uterine rupture with vaginal
sonography during the late second trimester in women with prior
cesarean. Obstet Gynecol 2000;95:596–600.
35 Coassolo KM, Stamilio DM, Pare E, Peipert JF, Stevens E, Nelson
DB, et al. Safety and efficacy of vaginal birth after cesarean
attempts at or beyond 40 weeks of gestation. Obstet Gynecol
2005;106:700–6.
36 Shipp TD, Zelop C, Repke JT, Cohen A, Caughey AB, Lieberman E.
The association of maternal age and symptomatic uterine rupture
during a trial of labor after prior cesarean delivery. Obstet Gynecol
2002;99:585–8.
37 Hamilton EF, Bujold E, McNamara H, Gauthier R, Platt RW. Dystocia
among women with symptomatic uterine rupture. Am J Obstet
Gynecol 2001;184:620–4.
38 The Confidential Enquiry into Maternal and Child Health (CE-
MACH). Saving Mother’s Lives: Reviewing Maternal Deaths to
Make Motherhood Safer 2003–2005. The Seventh Report of the
Confidential Enquiries Into Maternity Deaths in the UK. London:
CEMACH; 2007.
39 Smith GCS, Pell JP, Pasupathy D, Dobbie R. Factors predisposing to
perinatal death related to uterine rupture during attempted vaginal
birth after caesarean section: retrospective cohort study. BMJ
2004;329:375.
40 O’Brien-Abel N. Uterine rupture during VBAC trial of labour: risk fac-
tors and fetal response. J Midwif Womens Health 2003;48:249–57.
41 Hofmeyr GJ, Say L, Gulmezoglu AM. WHO systematic review of
maternal mortality and morbidity: the prevalence of uterine rupture.
BJOG 2005;112:1221–8.
42 Taylor DR, Doughty AS, Kaufman H, Yang L, Iannucci TA. Uterine
rupture with the use of PGE2 vaginal inserts for labor induction in
women with previous cesarean sections. J Reprod Med
2002;47:549–54.
43 Lydon-Rochelle M, Holt VL, Easterling T, Martin DP. Risk of uterine
rupture during labor among women with a prior cesarean delivery.
N Engl J Med 2001;345:3–8.
44 Lieberman E. Risk factors for uterine rupture during a trial of labor
after cesarean. Clin Obstet Gynecol 2001;44:609–21.
45 Grossetti D, Vardon C, Creveuil M, Herlicoviez M, Dreyfus M.
Rupture of the scarred uterus. Acta Obstet Gynecol 2007;86:572–8.
46 Buhimschi CS, Buhimschi IA, Patel S, Malinow AM, Weiner CP.
Rupture of the uterine scar during term labour: contractility or
biochemistry? BJOG 2005;112:38–42.
819
 Al-Zirqi et al.

47 Bujold E, Blackwell SC, Gauthier RJ. Cervical ripening with transcervi-
cal Foley catheter and the risk of uterine rupture. Obstet Gynecol
2004;103:18–23.
48 Royal College of Obstetricians and Gynaecologists. RCOG
Green-top Guideline No. 45: birth after previous caesarean birth,
February 2007 [www.rcog.org.uk/womens-health/clinical-guidance/
birth-after-previous-caesarean-birth-green-top-45]. Accessed 15
October 2009.
49 American College of Obstetricians and Gynecologists Committee on
Obstetric Practice. ACOG Committee opinion No. 342: induction of
labor for vaginal birth after cesarean delivery. Obstet Gynecol
2006;108: 465–8.
50 Society of Obstetricians and Gynaecologists of Canada. SOGC Clini-
cal Practice Guidelines. Guidelines for vaginal birth after previous
caesarean birth. Number 155 (Replaces guideline Number 147),
February 2005. Int J Gynaecol Obstet 2005;89:319–31.

Journal club

Discussion points
1. Objective and background: Compare the risks of trial of labour/attempt at vaginal birth after previous caesarean
section with the general risks of repeat caesarean section.
What are the main complications of uterine rupture? How is this different for women undergoing induction of
labour for intrauterine death?
2. Methods: Describe the design of this study and discuss its potential limitations.
The Equator website (www.equator-network.org) provides links to guidelines that facilitate both the writing and
the critique of scientific studies. Which guideline would be most useful for this study? Review the methods of this
study with reference to the relevant checklist. Discuss the advantages and disadvantages of deviating from the
structure described in the checklist.
3. Results and implications: Was there any difference in maternal or perinatal outcome between repeat caesarean and
attempt at vaginal birth (trial of labour)? Which were the other risk factors for adverse outcome? Were there any
‘protective’ factors? Discuss the implications for clinical practice.
How are women with previous uterine scar(s) and latent uterine activity (early labour) managed in your
practice/unit? What are the potential risks according to this study?
The risk of uterine rupture is increased with trial of labour as compared to repeat caesarean section in this study
but is still relatively low. What is your interpretation of the level of risk of rupture and adverse outcomes associated
with induction of labour, especially with prostaglandins? What is your current recommendation for women with an
unfavourable cervix who wish for a vaginal birth? What is the guidance in your unit/country? j
D Siassakos
Southmead Hospital, Bristol, UK
Email jsiasakos@gmail.com

820 ª 2010 The Authors Journal compilation ª RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology