When uterus ruptures, it's a race against time

Sandra* was wheeled into the operating theatre at 11.30am on a bright, sunny Christmas morning. There was a cheery mood in the theatre as staff celebrated the holiday at work. The labour ward was not busy and the holiday cheer was spreading to mothers in labour.
Sandra was due for an emergency caesarean section because she was in labour and had a history of a CS. What marked her as a high risk patient was that the interval between her last CS and the current labour, was less than a year. She had conceived when her baby was only two months old and it had been a hard psychological adjustment for her.
The thought of having two babies below the age of one year worried her and our anaesthetist went out of his way to reassure her all would be well while he prepared her for surgery. By the time I went to review her, she was cracking jokes about her situation in between the contractions and was looking forward to receiving her Christmas gift. She had opted for spinal anaesthesia and she was receiving high volume intravenous fluids in preparation.

LET OUT CRY
The scrub nurse was ready with her surgical tray by the time I was scrubbed up. The anaesthetist was ready to put Sandra under spinal anaesthesia and as he was about to position her for the procedure, she got another contraction. Suddenly, a muffled sound emanated from Sandra’s abdomen and she let out a cry and the contraction stopped.
The anaesthetist and I exchanged a look over the patient and sprang into action. With all the calm I could muster, I informed Sandra we thought her uterus had ruptured and it was a race against time to save her and her baby. The spinal anaesthesia was abandoned and Sandra was put under general anaesthesia in record time. The nurse and I cleaned and draped her abdomen and by the time the anaesthetist was giving us the go-ahead to start the surgery, we were ready.
The adrenalin in the room was at an all time high. The nurse receiving the baby was beside me with her towel draped over her hands ready to receive her. We went through the abdominal layers in a rush and as we entered the abdominal cavity, we were met with a pool of fresh blood. The baby had fallen out of the uterus into the abdominal cavity and we extracted her. The baby was delivered in a record four minutes!

EXCESSIVE BLEEDING
The baby was a tough little cookie. She came out sneezing and by the time her face had been wiped, she was grimacing away at the rude manner in which we had brought her into the world. By the time the nurse had put her on the receiving resuscitaire, she was yelling lustily while we were all cheering her on.
The miraculous survival of our baby was pegged on the fact that the placenta had not yet separated from the uterus and hence was able to continue providing the baby with oxygen. The placenta only remains in place for a short while before it separates and the baby is cut off from the life-sustaining oxygen. This is a normal chain of events because once a baby comes out of the uterus, the uterus has to contract so as to prevent excessive bleeding. The placenta is forced out. This will happen irrespective of the manner in which the baby is born.
Sandra survived the catastrophic event with minimal morbidity. We were able to repair the rupture of the uterus successfully and although she lost a substantial amount of blood, she did well and did not require a blood transfusion. We experienced a true Christmas miracle that day!
Uterine rupture is a traumatic event to both the patient and the caregiver. It bears a high mortality for both mother and baby and gives extremely short timelines for effective interventions to save lives. Many mothers are not as lucky as Sandra. When her rupture happened, we were ready for her. We recognised it immediately and we stepped right in, giving both of them a chance. Even where mothers survive, the baby hardly makes it because the placenta separates way before the patient makes it to the operating table.

SUSTAIN CONTRACTIONS
The uterus is a muscular organ which is highly elastic, with capacity to contract so strongly as to expel a baby out of the womb by itself. During uterine surgery, as may happen during C-section of myomectomy (removal of uterine fibroids), the smooth muscle fibres of the uterus are cut through. When sutured back together, the cut wound heals with formation of scar tissue, resulting in an interruption of the continuity of the uterine muscles.
A scarred uterus does not handle the force of contractions as efficiently as an intact one. This is why patients who have undergone C-section more than once, or those who have undergone myomectomy that scars the uterus, are no longer eligible for vaginal delivery.
Despite there being a criteria to help determine patients at higher risk of rupture of the uterus, it is not very accurate in predicting the likelihood of the actual occurrence. There are patients which such weak scars that will quietly start to rupture as a result of the stretch of the uterus during its expansion at pregnancy. They rupture even without contractions. This is the reason a woman may be advised against future pregnancy when her risk of rupture is considered to be unacceptably high.
Sandra remains a beacon of hope to care teams that handle women in their journey to motherhood. She demonstrates why we must continue to advocate availability of and access to hospitals that support safe motherhood and have capacity to handle emergencies. More importantly, the need for appropriately skilled and adequate number of healthcare providers to provide a safety net for mothers and babies.