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The Obstetrician & Gynaecologist 10.1576/toag.12.4.223.27613 http://onlinetog.org 2010;12:223–230 Review

Review Uterine rupture: a revisit

Authors Madhavi Manoharan / Rekha Wuntakal / Katrina Erskine

Key content:
• Uterine rupture is an uncommon complication of pregnancy associated with
potentially catastrophic consequences for both mother and baby.
• Previous uterine surgery is the most common underlying cause; however,
multiparous women without uterine scarring are also at risk if labour becomes
obstructed.
• A review of CEMACH reports has shown a consistent decrease in maternal
mortality secondary to uterine rupture despite increasing caesarean section rates.
• The risk of uterine rupture during attempted vaginal birth after caesarean section
is widely recognised; however, there needs to be greater awareness of this
emergency occurring in multiparous women undergoing
induction/augmentation of labour.

Learning objectives:
• To define uterine rupture.
• To examine the causes and risk factors for antepartum and intrapartum uterine
rupture.
• To review the signs and symptoms.
• To revise the management of uterine rupture.
• To increase awareness of this very serious complication and to suggest how
clinicians can make a case-based individual assessment of uterine rupture risk.

Ethical issues:
• Are those women at risk of uterine rupture adequately counselled about the
possibility and potential consequences?

Keywords CEMACH reports / maternal mortality / previous caesarean section / risk

factors / scarred uterus / vaginal birth after caesarean
Please cite this article as: Manoharan M, Wuntakal R, Erskine K. Uterine rupture: a revisit The Obstetrician & Gynaecologist 2010;12:223–230.

Author details
Madhavi Manoharan MRCOG
Clinical Fellow, Fetal Medicine
Department of Obstetrics and Gynaecology,
Homerton University Hospital NHS
Foundation Trust, Homerton Row,
London E9 6SR, UK
Email: madhumano70@yahoo.co.uk
(corresponding author)
Rekha Wuntakal MRCOG
Specialist Registrar in Obstetrics
and Gynaecology
Department of Obstetrics and Gynaecology,
Homerton University Hospital NHS
Foundation Trust, London, UK
Katrina Erskine MD MRCP MRCOG
Consultant Gynaecologist
Consultant Obstetrician and Gynaecologist
Department of Obstetrics and Gynaecology,
Homerton University Hospital NHS
Foundation Trust, London, UK

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Introduction
Uterine rupture is an uncommon but serious and
sometimes tragic occurrence. It can result in serious
complications for both mother and baby, such as
haemorrhagic shock, the need for peripartum
hysterectomy, hypoxic ischaemic encephalopathy,
permanent brain injury and even death.
It occurs most commonly in women with a scarred
uterus but this is not a prerequisite. Rupture of an
unscarred uterus is unexpected and diagnosis
may, therefore, be delayed. Outcomes in such cases
are possibly worse than after scar rupture during
vaginal birth after caesarean section (VBAC).
Definition
Symptomatic or complete uterine rupture is
defined as separation of the entire thickness of the
uterine wall, with extrusion of fetal parts and
intra-amniotic contents into the peritoneal cavity.1
Uterine dehiscence is defined as a disruption of the
uterine muscle with intact serosa.2 This is usually
asymptomatic. Diffentiation between the two
terminologies has not been consistent in many
studies. In a systematic review of uterine rupture
by Guise et al.3 the terms symptomatic and
asymptomatic uterine rupture were used to
distinguish between uterine rupture and
dehiscence.
Incidence
Uterine rupture occurs at a frequency of 1% in
women with a previously scarred uterus, with
retrospective studies quoting rates of approximately
0.65%.4 Rupture of an unscarred uterus is a rare
event, with the incidence being reported as 1/12
960 deliveries to 1/17 000 (Table 1).5–9
In contrast, a study from Nepal,10 a developing
country, quotes the incidence of uterine rupture
as 0.09 % (1/1100 live births). This was a
retrospective study spanning over 20 years
(272 245 live births) in a busy tertiary centre
with 16 000 deliveries a year and a caesarean
section rate of 11%. There were 251 uterine
ruptures (60% in an unscarred uterus, 29% in a
Population
Table 1
Study characteristics
Incidence of uterine rupture
Miller et al. (1997)5 Included only women
retrospective review with unscarred uterus
Ofir et al. (2003)6 10% of women had
retrospective review previous scar
Landon et al. (2004)7 All LSCS and 1 LSCS
prospective study scars allowed
Landon et al. (2006)8 All women had LSCS scar
prospective study
Bashiri et al. (2008)9 All had LSCS, multiple
retrospective review LSCS included
LSCS  lower segment caesarean section
224
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scarred uterus and 11% were traumatic
ruptures) with a mortality rate of 7.9%. Of the
deaths, 2% occurred before intervention
because of arrival in a moribund condition.
Most women were multiparous, in their third or
fourth pregnancy. The main concerns were poor
or no antenatal care and failure to recognise the
symptoms of uterine rupture. This wide
variation in incidence between developed and
developing countries is probably related to
issues with access to care and inadequate
intrapartum care.
Risk factors for uterine
rupture
See Box 1.
Antepartum
Rupture during pregnancy is rarely reported
from motor vehicle accidents.11,12 It can also occur
in women with a previously scarred uterus,
particularly if this involves the upper segment,
where it classically occurs before labour and
before term.13 Several cases of spontaneous
rupture of the uterus during pregnancy following
previous myomectomy have been reported.14 No
difference in adverse pregnancy outcomes such as
uterine rupture was noted in a study comparing
laparoscopic myomectomy with open
myomectomy.15 Larger series evaluation is needed
to confirm this finding.
The nulliparous uterus has been described as
being ‘virtually immune to rupture’, 16 especially
before the onset of contractions. Isolated case
reports of rupture in primigravid women have
been described in association with connective
tissue disease such as Ehlers-Danlos syndrome,17
chronic steroid use17 and cocaine misuse.18
Müllerian anomalies of the uterus 19 and
abnormal placentation, especially placenta
percreta,20 have been associated with ruptured
uterus and can occur from the second trimester.
More recently, several less common risk factors
such as previous difficult uterine curettage and
Incidence of
Definition Sample size uterine rupture
Only uterine rupture 16 849 deliveries 1 in 16 849 deliveries
reported (0.006%)
Only complete rupture 117 685 singleton 0.035%
reported deliveries
Both rupture and dehiscence 17 898 deliveries 0.7%
reported separately
Only uterine rupture Single previous 0.7%
reported LSCS: 16 915 deliveries
Multiple LSCS: 0.9%
975 deliveries
Only uterine dehiscence 7833 deliveries 1.03%
reported
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operative hysteroscopy (hysteroscopic During pregnancy Box 1

metroplasty) have been identified, especially • Previous classical caesarean section
Causes of uterine rupture
when they have been complicated by uterine • Previous hysterotomy (very rare)
perforation.21 Women should be counselled • Previous myomectomy
regarding these risks and evaluation for residual • Placenta accreta
damage with hysterography may be useful. • Motor vehicle accidents
Hysterography may demonstrate a defect or • Müllerian anomalies of uterus
fistula in the uterine wall, which may be • Hysteroscopic metroplasty
considered sufficient evidence to consider • Difficult curettage for miscarriage
delivery by planned caesarean section and, in Rare causes described in primigravida women
some cases, interval repair. 22 • Ehler–Danlos syndrome
• Chronic steroid use
Intrapartum • Use of cocaine
The most common risk factors for intrapartum
During labour
rupture in an unscarred uterus are grand
• Previous caesarean section
multiparity; fetal malpresentation, such as
• Previous myomectomy
unrecognised brow, face and shoulder
• Grand multiparity
presentation; cephalopelvic disproportion; and
• Malpresentation: unrecognised brow, face and shoulder
oxytocin augmentation in multiparous presentation
women. Less common risk factors are assisted • Unrecognised cephalopelvic disproportion
breech delivery, instrumental delivery • Obstructed labour
(injudicious use of Kielland forceps), tumours • Prostaglandin and oxytocin augmentation in women with
obstructing the birth canal and pelvic high parity and previous caesarean section
deformity. 6 • Use of high doses of misoprostol in parous women
• Instrumental delivery (injudicious use of Kielland
forceps)
A number of case reports have been published
• Assisted breech deliveries
detailing uterine rupture occurring in
Rare causes
association with the use of misoprostol as an
• Tumours obstructing the birth canal
induction agent, in both primiparous and
• Pelvic deformity
multiparous women.23 Caution should be
exercised with the use of misoprostol in Post delivery
multiparous women and in women with a • Precipitate labour
previously scarred uterus, even in the context of • Manual removal of placenta
intrauterine fetal death or termination of • Uterine manipulation (intrauterine balloon)
pregnancy. • Placenta accreta

Intrapartum rupture is a well recognised
complication of labour when a uterine scar
exists. The risk is undoubtedly related to the site
of the uterine scar and probably to the number
of previous uterine surgeries (Table 2).7,8,24–26
A case control study29 has noted an increased
risk of uterine rupture during VBAC in women
who experienced postpartum fever following
their previous caesarean delivery (odds ratio
4.0, 95% CI 1.0–15.5).

A retrospective study 27 found that women with Opinions are divided over the issue of rupture
previous preterm caesarean section had the risk in labour following previous
same risk of uterine rupture as women with myomectomy. Recent retrospective analysis
previous term caesarean section, suggesting
that gestation per se at the time of caesarean
Site and type of uterine scar and
section does not influence subsequent rupture number of previous uterine surgeries Incidence (%)
Table 2
Incidence of rupture in women with a
risk. In this study 98% of women had a lower One previous lower segment scar scarred uterus
tranverse incision. Landon et al. (2006)8 0.7
SOGC (2005)25 0.2–1.5
Two previous lower segment scars
Whether method of closure (single/double Caughey et al. (1999)24 3.7
Previous low vertical incision
layer) at the time of primary caesarean section Landon et al. (2004)7 2
has a role to play in the risk of subsequent ACOG (2004)26 1–7
SOGC (2005)25 1–1.6
rupture is not clear. The incidence of uterine Unknown prior incision
rupture in women who had single-layer closure Landon et al. (2004)7 0.5
Previous classical/inverted T/J-shaped incision
is one of the long-term outcomes being studied Landon et al. (2004)7 1.9
in the CAESAR study. The findings of this study ACOG (2004)26 4–9
Two or more previous caesarean births
are eagerly awaited. In the largest trial to date, Landon et al. (2006)8 0.9
single-layer closure was strongly associated with ACOG  American Congress of Obstetricians and Gynecologists;
subsequent uterine rupture.28 SOGC  Society of Obstetricians and Gynaecologists of Canada

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Table 3
Risk of uterine rupture and
induction/augmentation of
labour in women with a
previous low transverse scar
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2010;12:223–230
Study Incidence of rupture
Grossetti et al. (2007)32
Not in labour
In spontaneous labour
Oxytocin-induced labour
Prostaglandin cervical ripening
Kwee et al. (2007)33
PGE2 alone or combined with oxytocin OR 6.8, 95% CI 3.2–14.3
augmentation
Oytocin augmentation OR 2.2, 95% CI 1.04–5
Locatelli et al. (2006)34
Prostaglandin and oxytocin induction 0.3% (no difference)
Kayani and Alfirevic (2005)35
Induction of labour 2.4%, 95% CI 0.8–5.6
Yogev et al. (2004)36 No difference noted
OR  odds ratio; PGE2  prostaglandin E2
shows that this group of women does have a
greater risk of scar rupture. 30 The general
opinion is that it is safe for women who have
had previous myomectomy to aim for vaginal
birth provided the endometrial cavity has not
been breached, but the evidence base is
sparse. 31
Induction of labour either with oxytocin or
prostaglandins is an independent risk factor for
uterine rupture in women with a scarred uterus
(Table 3) . 32–36
Use of misoprostol as an induction agent in
women with a previous scar is associated with an
increased risk of uterine rupture of 5.6%.37 Unlike
prostaglandins or oxytocin, cervical ripening with
transcervical Foley catheters in women with
previous caesarean delivery is not associated with
increased risk of uterine rupture.38
Certain demographic factors have been
identified as markers of higher rupture risk.
Retrospective reviews of women attempting
VBAC have shown that among the different
racial groups, black women are 40% less likely
to experience uterine rupture, 39 despite
increased rates of VBAC attempt and VBAC
failure. A possible explanation for this racial
disparity is that it could be due to ethnic
differences in pelvic connective tissue, as shown
by differences in rates of pelvic organ prolapse 40
and collagen composition.41
Women aged 30 years have a greater risk of
uterine rupture than women aged 30 years,42
although more recent studies have not shown
this association.6
Short interpregnancy interval (6 months) has
been found to increase the risk of uterine
rupture two to three-fold in women attempting
trial of labour following caesarean delivery. 43
In a cohort study, Hammoud et al.44
demonstrated that increasing gestational age of
at least 41 weeks at the time of trial of labour
was associated with a significantly higher rate of
uterine rupture.
The Obstetrician & Gynaecologist
Diagnosis
0.3%
Signs and symptoms of uterine rupture are
1.0% varied. The woman can sometimes be
1.4%
2.2%
asymptomatic: this occurs when the fetal sac
herniates through an avascular scar and the
uterus retracts.
Prior to uterine rupture, the woman may
exhibit restlessness and constant pain in the
lower part of the uterus. She may become
tachycardic and have tetanic uterine
contractions with CTG abnormalities such as
sudden and persistent bradycardia consistent
with fetal compromise. The fetal parts may
become difficult to palpate. Bandl’s ring is
described as a late warning sign of impending
rupture. It is a pathological retraction ring
which demarcates the junction of the thinned
lower uterine segment and the thick retracted
upper uterine segment. Bandl’s ring usually
appears before uterine rupture when it occurs
secondary to obstructed labour.
Following rupture, the woman may describe a
sudden feeling of something giving way with
complete cessation of uterine activity.
On examination a loss of uterine contour may
be identified and two swellings may be
distinguished: one is the fetus lying in the
abdominal cavity and the other is the contracted
and retracted uterus. The fetal parts may then
be easily palpable. Vaginal bleeding is a rare
occurrence. Vaginal examination will reveal a
receding presenting part. Bleeding into the
abdominal cavity can be profuse and the woman
may present with shock and collapse. The
amount of bleeding depends on the location of
the scar relative to the vessels. Rarely, rupture is
recognised only after delivery of the baby and
should be a differential diagnosis for
postpartum collapse. If the rupture extends into
the broad ligament, the woman can present with
gradually increasing abdominal pain and a very
tender abdominal mass.
An abnormal cardiotocograph is present in
55–87% of uterine ruptures, 3 with bradycardia
being the most common fetal heart rate
abnormality.
No particular pattern of uterine activity is
pathognomonic of uterine rupture, 45 although
one case report described the ‘staircase sign’ as
characteristic of uterine rupture. This sign
classically describes a stepwise gradual
decrease in contraction amplitude followed by
the sudden onset of profound and prolonged
fetal bradycardia which can be demonstrated
by both external and internal pressure
transducers. 46 Uterine contraction pattern may
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differ depending on the presence or absence of
a pre-existing scar or with the site and
direction of rupture. This explains the
contradictory reports in the literature. These
are anecdotal reports and the practicality of
routine use of intrauterine transducers is
questionable.
Management
Diagnosis of uterine rupture warrants
resuscitation and exploratory laparotomy. The
importance of immediate senior involvement
and teamwork cannot be overemphasised.
Repair of the uterus is possible in the majority
of women. In others, haemorrhage from
extension of the rupture into the broad
ligament or extensive damage to the uterus
requires hysterectomy.
Hysterectomy rates following uterine rupture
have been quoted as 3.4/10 000 women choosing
trial of labour following caesarean section. 3 The
risk of hysterectomy following uterine rupture
in women with previous caesarean section is
4–13%.47–51 No difference has been noted in the
rates of hysterectomy in pregnancies with
uterine rupture in women with scarred and
unscarred uterus. 1
Postoperative care is equally important as
uterine rupture is associated with a high risk of
bladder injury, massive transfusion because of
haemorrhage, admission to intensive care,
endometritis and longer hospital stay.
A review of the literature found that 5% of
symptomatic uterine ruptures were associated
with perinatal mortality and that 7142 elective
repeat caesarean sections were required to be
performed to prevent one rupture-related
perinatal death. The additional risk of perinatal
death from rupture of uterine scar was
1.4/10 000.3
Maternal death due to uterine rupture following
trial of labour in a review of the literature
(142 075 women) has been quoted as 0.002%.52
In the same study, neonatal acidosis was seen in
0.15% and perinatal death in 0.04% as a
consequence of uterine rupture. Significant
neonatal morbidity can occur when
18 minutes have elapsed between the onset of
prolonged deceleration and delivery.53
Rupture occurring in an unscarred uterus is
associated with high rates of fetal loss and
higher rates of hysterectomy. 54 Rupture of a
previously scarred uterus is usually incomplete
and the tear is transverse, therefore, maternal
and fetal prognosis is much better and repair of
the uterus is often feasible.55
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2010;12:223–230 Review
Is it possible to predict
uterine rupture antenatally?
Several models for antepartum prediction of
risk of failed VBAC and thus of possible uterine
rupture have been formulated. Smith et al.56
postulated a method similar to that used for
trisomy 21 screening from risk factors identified
in the antenatal period. They found that women
with high predicted caesarean section risk also
had a higher risk of uterine rupture (odds ratio
for a 5% increase in predicted risk  1.22,
95% CI 1.14–1.31).
A more user-friendly scoring system to quantify
the risk of symptomatic uterine rupture based
on factors identified at the first antenatal visit
has been reported.57 Risk factors identified early
in pregnancy such as an inter-delivery interval
of 18 months, maternal age of 30–39 years,
maternal age 40 years, two or more prior
caesareans and prior vaginal delivery are
assigned numerical scores ranging from 1 to
2. The rate of uterine rupture varies by the total
score: 1  0.26%; 0  0.25%; 1  1.11%;
2  2.43%; 3  3.70%; and 4  14.29%, P  0.001.
Measurement of the thickness of the lower
uterine segment by ultrasound in the third
trimester can be performed and a value of
3.5 mm has been found to carry a significant
negative predictive value (99.3%). 58 This was a
prospective observational study of 642 women
in France which found that the risk of uterine
rupture and dehiscence was directly related to
thinning of the lower segment at around
37 weeks. With a positive predictive value of
only 11.8%, however, further studies are
warranted. There is no evidence that
measurement of thickness of the lower segment
is superior to careful clinical practice in the
prevention of uterine rupture. Moreover, all the
ultrasound examinations and interpretation in
this study were carried out by a single
investigator. Hence questions regarding the
reproducibility and accuracy of ultrasonic
assessment of scar thickness in routine clinical
practice have been raised. 59
Is it possible to predict
uterine rupture during
labour?
Use of a simple tool such as the partograph in
the prediction of uterine rupture has been
reinforced by Khan and Rizvi.60 They predicted
that the partographic zone 2–3 hours after the
alert line in women undergoing trial of labour
following caesarean section represents a time of
high risk of rupture. Women attempting VBAC
should, therefore, be closely observed for
progression of labour. Recognition of active
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phase arrest disorders, in both multiparous
women and those aiming for VBAC, should
prompt senior obstetric involvement and a
careful risk–benefit analysis of continuing the
labour against immediate delivery by caesarean
section, or instrumental birth if appropriate.
Many would consider these situations as an
absolute contraindication to the use of oxytocin
augmentation.
Clinical judgement is very important in the
diagnosis of uterine rupture, as no scoring
system is totally reliable in predicting the risk.
Pregnancy following uterine
incidence of uterine rupture in a scarred uterus.
Fortunately, this has not been the case in the UK
because of increased awareness and meticulous
monitoring. The present trend appears to be for
rupture, when it happens, to occur in an
unscarred uterus with the use of prostaglandins
and non-recognition of the warning signs and
symptoms. For example, the CEMACH report of
2000–200263 describes the case of a woman who
had induction of labour with prostaglandins
and went on to have a precipitous labour and
forceps delivery. Subsequently, she collapsed
and on laparotomy a uterine tear was noted. She
underwent hysterectomy but died after several
days in intensive care.

rupture The CEMACH report of 2003–200564 reported one

Table 4
Summary of causes of maternal
death from uterine rupture
1955–2005
If the uterine rupture is confined to the lower death from uterine rupture. High doses of
segment, the risk of rupture in a future prostaglandin E2 were given to a parous woman
pregnancy is 6%; if the rupture involves the with previous precipitous labour. In this induced
upper segment, the risk is increased to 32%.61 labour she also laboured extremely quickly and a
Women who have had a previous uterine fetal bradycardia was followed by rapid delivery.
rupture are, therefore, advised to give birth by Subsequently, she became haemodynamically
repeat caesarean section prior to onset of labour. unstable because of massive intra-abdominal
haemorrhage. Laparotomy with hysterectomy was
Maternal mortality performed but she died later.
Maternal death from uterine rupture is rare.
The rate is less than 1/100 000 cases in women Uterine rupture can be prevented if women are
having a trial of labour in the developed world. 62 assessed for risk factors antenatally and a plan
Causes of maternal death as detailed in the for delivery is documented in the notes.
Confidential Enquiry into Maternal and Child
Health (CEMACH) (1955–2005) are briefly Risk management
summarised in Table 4. Despite the remote risk of uterine rupture in
grand multiparous women and those attempting
With an increasing caesarean section rate the trial of labour following caesarean delivery and
worry is that there will be an increase in the the lesser subsequent risks of maternal or fetal
death from this catastrophe, the gravity of these
Number of cases
Year of uterine rupture Causes of rupture and death
risks warrants detailed discussion.
1955–1957 33 Obstructed labour/uterine
manipulation (5 VBAC, 2 MRP, 8 In view of the increased risk of ruptured uterus in
multiparas)
1964–1966 30 Obstructed labour/traumatic
women with previous caesarean delivery undergoing
delivery induction of labour with prostaglandins or oxytocin,
1967–1969 19 9 traumatic, 8 spontaneous, 2
scar ruptures. Delay performing
the decision to proceed should only be made after
laparotomy in suspected cases obtaining a fully informed consent. In addition, the
1973–1975 11 Inappropriate use of oxytocin
1978–1981 4 All in women with scarred uterus,
process of obtaining informed consent must be
with delay in diagnosis and secured without coercion. Many obstetric units in
performing caesarean section
1991–1993 4 Genital tract trauma including
the UK consider it prudent to avoid using
uterine rupture. Inadequate prostaglandins to induce and oxytocin to induce and
supervision of junior doctors
1994–1996 5 Use of prostaglandin in women
augment labour in women undergoing a trial of
with scarred uterus, failure to VBAC. Delivery should be offered to women in a
identify intraperitoneal bleeding in
a known case of placenta accreta.
hospital setting where timely operative delivery is
Two occurred in primigravidae: one available; this includes availability of obstetric,
had a traumatic vaginal delivery
and the other presented in early
anaesthetic, paediatric and theatre staff.25
labour with hypovolaemic shock
1997–1999 1 Failure to identify uterine rupture
following ventouse delivery in a
Prior successful VBAC offers some protection
woman undergoing trial of scar from uterine rupture, as shown in a large
2000–2002 1 Prostaglandin for IOL and
precipitous labour
prospective multicentre study.65 Risk of uterine
2003–2005 1 Use of repeated doses of rupture decreased after one successful VBAC and
prostaglandin E2 in a parous
woman
did not change substantially with additional
IOL  induction of labour; MRP  manual removal of placenta;
prior VBAC. Women with one or more prior
VBAC  vaginal birth after caesarean successful VBAC attempts were found to have

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approximately half the risk of uterine rupture of
those attempting their first VBAC (0.4–0.5%
compared with 0.9%). Thus, successive labours
in women with previous caesarean delivery do
not place additive or multiplicative strain on the
uterine scar. This is important in counselling
women who are planning VBAC.
Clinical management decisions ultimately rest
with the woman; our role as clinicians is to
convey accurate information that will assist
women to make informed decisions. The final
decision should also take into consideration any
wish for future pregnancies.
Conclusion
Uterine rupture is a rare complication but it has
potentially catastrophic implications for both
mother and baby. It is associated with high
maternal and fetal mortality and morbidity. In
theory, an increase in uterine rupture is expected
with increasing caesarean section rates. This has
not been the case in the UK because of increased
vigilance, rigorous monitoring in labour and the
adoption of strict interventional criteria. In the
past, parous women with an intact uterus have
been overlooked and this is reflected in the
maternal deaths due to uterine rupture in the
last two CEMACH reports.63,64
The aim should be to prevent this serious
complication from occurring. The authors believe
that this can only be achieved by increasing
awareness among doctors and midwives and
counselling women adequately. Both doctors and
midwives require adequate training to detect the
early warning signs and symptoms of uterine
rupture, as they are non-specific.
Equally important is the assessment of risk factors
for uterine rupture, both antenatally and in the
intrapartum period. The authors suggest that
this should be flagged up in the antenatal notes,
including a plan for delivery and use of
prostaglandins for induction of labour.
Caution should be exercised during oxytocin
augmentation, especially in poorly progressing
multiparous women and those with a history of
prior caesarean section. Senior input is vital in
these decisions.
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