Journal of Perinatology (2012) 32, 837843

r 2012 Nature America, Inc. All rights reserved. 0743-8346/12

www.nature.com/jp

ORIGINAL ARTICLE

Severe maternal and perinatal outcomes from uterine rupture

among women at term with a trial of labor
MK Barger1, A Nannini2, J Weiss3, ER Declercq3, P Stubblefield4, M Werler5 and S Ringer6
1

Family Health Care Nursing, University of California, San Francisco, San Francisco, CA, USA; 2Department of Nursing,
University of Massachusetts Lowell, Lowell, MA, USA; 3Department of Community Health Sciences, Boston University School of
Public Health, Boston, MA, USA; 4Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston,
MA, USA; 5Slone Epidemiology, Boston University, Boston, CA, USA and 6Newborn Medicine, Brigham and Womens Hospital,
Harvard Medical School, Boston, MA, USA

Objective: To describe maternal and perinatal morbidity and mortality

associated with uterine rupture (UR) among women with prior cesarean/s,
singleton term pregnancies and a trial of labor after cesarean (TOLAC).

Study Design: Linked hospital discharge files and birth/fetal death

certificates identified potential cases of UR in Massachusetts from 1990 to
1998 with definitive identification by medical record abstraction.
Result: Among the 347 identified URs, severe outcomes occurred in
86 cases (25%), in 49 (14%) of mothers and 49 (14%) of infants. Of the
infants, 25 were discharged with a good prognosis. Maternal age and
interdelivery interval <18 months (relative risk (RR) 1.55; 95%
confidence interval (CI): 1.05, 2.31) were associated with a severe
outcome. The type of hospital and labor were not associated with the
increased risk of a severe outcome.
Conclusion: Assuming a 0.7% UR rate among women at term with
a TOLAC, the increased rate of severe outcomes related to UR above the
baseline risk of elective cesarean is estimated to be 1.3 per 1000 TOLACs.
Journal of Perinatology (2012) 32, 837843; doi:10.1038/jp.2012.2;
published online 22 March 2012
Keywords: uterine rupture; trial of labor; vaginal birth after cesarean;
maternal outcomes; neonatal outcomes

Introduction
The consequences of uterine rupture (UR) before, during or after
birth can range from inconsequential to catastrophic for mother
and/or baby. Among women with a previous cesarean who undergo
a trial of labor after a cesarean (TOLAC), UR is still a relatively
rare event (0.3 to 0.7%).1,2 A recent review of vaginal birth after
cesarean (VBAC) has noted a paucity of evidence on identifying
Correspondence: Dr S Ringer, Newborn Medicine, Brigham and Womens Hospital, Harvard
Medical School, 75 Francis Street, Boston, MA 02115, USA.
E-mail: sringer@partners.org
Received 8 July 2010; revised 28 November 2010; accepted 3 December 2010; published online
22 March 2012

those at risk for adverse outcomes.1 As the overall (31.1% in 2006)

and primary (23.5%) cesarean rates continue to rise,3,4 putting
more women at risk of UR, identification of the clinical and
demographic factors associated with severe outcomes is needed
by providers to counsel patients appropriately.
Although immediate maternal outcomes from UR have been
reported in many studies, fewer studies have followed infant
outcomes beyond reporting perinatal death rates.1 Most of these
studies have been from single institutions, typically academic
medical institutions, with the exception of the multicenter
prospective cohort study reported by Landon et al.2 conducted at
19 academic medical centers. The only two previous populationbased studies using clinical databases to investigate maternal
and perinatal outcomes following UR were conducted outside
the United States.5,6
The Massachusetts Uterine Rupture Study was undertaken to
identify all true cases of UR between 1990 and 1998, regardless
of the history of previous cesarean or gestational age, using a
combination of linked administrative data and information from
abstracted medical records.7 This paper focuses on the subgroup
of women identified in the study who had a singleton, term
pregnancy and who attempted a VBAC and experienced a UR.
During the study period, the rate of VBAC in Massachusetts reached
a peak of 34% in 1996, 6 percentage points higher than the
national rate, making Massachusetts an appropriate setting in
which to study outcomes among women with a trial of labor.
We studied UR cases to assess the severity of maternal and
fetal/neonatal outcomes among this population, and to identify
possible demographic, obstetric and labor management risk
factors associated with a severe outcome related to the UR.

Methods
Suspected cases of UR were identified from hospital discharge data
for all Massachusetts deliveries between 1990 and 1998, using one
of three International Classification of Diseases-9 diagnosis codes

Severe outcomes from uterine rupture

MK Barger et al

838

(665.0/1, 664.1) for UR.7 Suspected case hospital discharge files

were linked with birth and fetal death certificates, and maternal
and infant death files.
A limited medical record containing the face sheet, discharge
summary and delivery or surgical reports were obtained for 97.5%
of the 1488 suspect cases. Each record was reviewed by two
clinicians (from a team of three obstetricians and one nursemidwife) to confirm a UR. A total of 573 cases met the definition
of any unintentional disruption of the complete uterine wall
including the visceral peritoneum in a pregnant woman, regardless
of size, degree of severity or location.7 Of the 573 cases, the
complete medical record was obtained for 566 women (see
Figure 1). Trained obstetrical nurses abstracted data from the
charts of mothers using a structured abstraction protocol. A 10%
random sample of independently abstracted charts showed 99%
agreement between abstractors on variables used in this analysis.
For this study, subjects had to meet the four principal study
criteria: (1) singleton pregnancy; (2) delivered between 37 and
42 weeks of gestation; (3) previous cesarean; and (4) underwent
a trial of labor. Trial of labor was defined using the Maryland
Quality Indicator Project definition: the attempt to establish a
pattern of uterine contractions in a gravid woman with a history
of a previous cesarean.8
Data on subjects were drawn from four sources: (1) birth
certificate or fetal death record linked to the associated electronic
hospital discharge records that included a unique identification
number, which in most cases was an encrypted social security
number; (2) the mothers hospital delivery record; (3) her prenatal
record contained in the hospital delivery record by law; and (4) the
medical record of infants who died before discharge and/or had a
5-min Apgar score of <7. Longitudinally linked hospital discharge
records were used to assess both maternal and neonatal morbidity,
and linkage to mortality records identified mothers and infants

who died within 1 year of the birth. The unique identification

number allowed linking to any other hospital discharge data that
identified if any women were re-admitted to any Massachusetts
hospital within 6 weeks of the birth. All infant records from the
birth hospital and hospital to which an infant may have been
transferred were reviewed until the baby was discharged home from
either the birth or transfer hospital.
The Massachusetts Department of Public Health Human
Research Review Committee approved this study.
Outcome definition
For mothers, a severe outcome was defined as having a
hysterectomy, need for mechanical ventilation or a blood
transfusion or a maternal death. Other potential variables for
maternal severity were examined: admission to an intensive care
unit, development of adult respiratory distress syndrome and organ
failure; however, every woman experiencing these events also had a
blood transfusion. Severe infant outcomes included perinatal
death (fetal or neonatal), a 5-min Apgar score of <4 or a 5-min
Apgar score of 4 to 6 requiring assisted ventilation.
Outcomes were categorized based on relatedness to the rupture,
with and without comorbidities that may have contributed to the
poor outcome. An obstetrician and nurse-midwife independently
rated each hysterectomy (which included the one maternal death
in the study). A hysterectomy was rated as related to the rupture if
no obvious comorbidity or other agent for bleeding was identified.
A hysterectomy was rated as unrelated to the rupture if there was a
placenta percreta or increta, or if bleeding was from the placental
site or another site clearly unrelated to the rupture, such that
a hysterectomy would have been required regardless of the rupture.
Two neonatologists independently reviewed the infant records
to determine relatedness of perinatal outcomes to the rupture. A
death or low Apgar score was related to the rupture if no other

1526 Suspect Cases from

Hospital Discharge Data Files 1990-1998
1488 (94.9%)
Suspect charts reviewed

915 (61.5)
Not a uterine rupture

573 (38.5%)
True uterine rupture

6
Multiple gestation

566 (98.7%)
full medical record abstracted

49
<37 weeks gestation

511
Prior cesarean, singleton pregnancies

461
37-42 weeks

114 (25%)
No trial of labor

Figure 1 Massachusetts uterine rupture study population. CS, cesarean section.

Journal of Perinatology

347 (75%)
Trial of labor

49 No prior CS

Severe outcomes from uterine rupture

MK Barger et al

839

condition was noted that could be responsible for the poor

outcome. Comorbidities included other conditions that could have
contributed to the infants condition. An outcome was unrelated to
the rupture if another condition, for example congenital anomaly,
was present and the rupture was an incidental finding. Examples of
reasons to classify a rupture as an incidental finding included
fetal demise before labor, coupled with evidence that the UR
occurred late in labor, and the death of an infant with a lethal
congenital anomaly at a time remote from the UR event. Hypoxic
ischemic encephalopathy was identified when the Sarnat score was
greater than stage 1.9 In addition, the neonatologists independently
rated the prognosis of infants on discharge home as either poor/
fair or good based on the infants hospital course. Maternal or
fetal/infant mortality or severe morbidity rated as related to the UR
was defined as a severe UR.
Variables of interest
Maternal demographic characteristics were obtained from the birth
certificate or hospital record if missing. Hospitals at which women
delivered were categorized according to the Massachusetts
Department of Public Health perinatal regulations, which are based
on the ability to care for premature infants.10 For the purposes of
this paper, descriptive terms were chosen as labels for these
categories. Small community hospitals had lower delivery volume
and no nurseries to care for infants <34 weeks. Larger
community hospitals have a larger delivery volume and units that
can care for infants of >31 weeks of gestation. Tertiary Care
hospitals have neonatal intensive care units prepared to care for
any infant. Maternal reproductive history and medical conditions
were abstracted from the medical record.
Labor management variables obtained from the medical record
included whether labor was induced or spontaneous, and the use of
cervical ripening agents and oxytocin. Labor induction with
oxytocin was differentiated from its use for labor augmentation.
The maximum dose of oxytocin was recorded in milliunits per
min, and the duration of use in continuous hours of use. If
oxytocin was used for <30 min, it was recorded as 0 h, and if it
was discontinued for >2 h, the duration was defined as the last
period of continuous use.
Abstracted data included any morbidities encountered during
the hospital stay such as the extent of rupture, amount of blood
loss and any associated use of blood and blood products and
intensive care measures for both mother and infant.
Mean values of continuous variables were compared using
t-tests. Variables were also categorized based on the distribution of
the data, and analyzed as categorical variables. Univariate analysis
was done to assess the relation between variables and severe UR.
Stratified analyses were conducted to assess confounding. If a
variable associated with severe rupture was also associated with the
exposures and it changed the risk estimate by >10% after
adjustment, it was considered a confounder and was included in

the final adjusted model. No variables met this definition.

Therefore, unadjusted risks and 95% confidence intervals (95% CIs)
were calculated using log-binomial multivariable regression to
determine association between categorical variables and severe UR.
The statistical model was fit using PROC GENMOD with binomial
errors and a log-link function using SAS, version 9.1 (SAS Institute,
Cary, NC, USA).

Results
There were 461 women identified with a true UR at term with a
singleton pregnancy of whom 347 underwent a TOL. Five women
were re-admitted after discharge, 3 of them were women who had a
TOL and whose re-admission was related to a severe outcome.
Table 1 presents the number and types of maternal and perinatal
severe morbidities for the women who underwent a trial of labors.
Of these pregnancies, 25% involved a severe outcome. In
comparison among 114 women without a TOLAC and a UR, 6.1%
(N 7) had a severe outcome, 4 with severe maternal morbidity
and 5 with perinatal morbidity or perinatal death.
Among those undergoing a TOLAC, there were 49 (14%) severe
maternal outcomes and 49 (14%) severe perinatal outcomes,
among which 12 had both a severe maternal and perinatal

Table 1 Severe perinatal and maternal morbidity and mortality related to

uterine rupture
Trial of labor (N 347)
Number (%)
Severe outcome for mother or infant
Any maternal morbidity or death
Hysterectomy
Assisted ventilation
Intensive care unit admission
Transfusion
1 to 2
34
X5
Shock

86
49
20
10
19
43

(24.8)
(14.1)
(41.7)a
(20.8)a
(39.6)a
(87.8)a
24
5
14
21 (42.8)a

Any perinatal morbidity or death

Perinatal deaths
Neonatal/infant morbidity
The 5-min Apgar <4
The 5-min Apgar 46 and required ventilation
Umbilical artery blood pH <7a
Hypoxic-ischemic encephalopathy or presence
of seizures

49
10
39
17
22
8
9

(14.1)
(2.9)
(11.3)
(43.6)a
(56.4)a
(26.7)a,b
(23.1)a

Percent within morbidity category.

Umbilical artery blood pH documented in 30 infants.
Both mother and infant had a severe outcome for 12 deliveries among those with a trial
of labor and 3 of those without a trial of labor.

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840

outcome (Table 1). Among the TOLAC group who experienced

a severe maternal outcome, including the one maternal death,
some had multiple severe outcomes; that is, the same woman
might be counted in more than one category in Table 1. Of the
20 hysterectomies related to UR, 4 had comorbidities thought to
contribute to the hysterectomy, for example, presence of a low-lying
placenta or possible damage to the uterus from instruments.
There were two hysterectomies that were unrelated to UR. All but
three women having hysterectomies required a blood transfusion.
There were 18 women whose only morbidity was blood transfusion,
and of these, half required other blood component therapy or
volume expanders.
Of the 49 (14%) with a severe perinatal outcome, 2 infants had
a contributing comorbidity. Of these infants, 14 (31% of those with
a severe outcome) required transfer from their birth hospital to
another hospital. There were 10 perinatal deaths (5 fetal and
5 neonatal); this does not include 3 deaths assessed to be unrelated
to the UR, 1 fetal demise before labor and 2 from congenital
anomalies remote from time of UR. Of the 22 infants who had
5-min Apgar scores of 4 to 6 and required mechanical ventilation,
6 (27%) were extubated and in good condition within 1 day of
birth. The median cord pH of infants born alive was 6.83 (range of
6.22 to 7.29), and slightly more than one-quarter of infants
in whom umbilical artery blood pH was measured had a pH of
<7.0. A similar percent was diagnosed with hypoxic-ischemic
encephalopathy or seizures during their hospital stay. Overall,
slightly over half (N 25) of infants with a severe outcome were
discharged home with a good prognosis. This represents 64.1% of
the infants born alive.
The obstetrical histories of women with and without severe
outcomes were also generally similar, although a nonsignificantly
larger percent of women without a severe outcome had a parity of
X3 (Table 2). The distributions of any vaginal birth, previous
vaginal births, VBACs and previous cesareans were similar between
the two groups.
All women in the study had one or two previous cesareans,
with the exception of one woman who had three. Among those
with documented scars (92%), all women except three had low
transverse incisions. Of the three women, two were low vertical and
one was classical. Only one woman had other uterine surgery.
Data comparing those with and without a severe UR on the
presence of symptoms, stage of labor and method of delivery are
also presented in Table 2. Of note, 15% of women who experienced
a severe outcome did not have any of symptoms (that is, bleeding,
pain or fetal distress) that would meet the definition of a
symptomatic UR. Over half (55%) of the women delivering
vaginally experienced a severe outcome compared with 21% of
those delivering by cesarean. This may be because of
underreporting of inconsequential URs among women delivering
vaginally. Women who deliver by VBAC with no sequelae generally
do not have their uterus explored for a UR and, therefore, more
Journal of Perinatology

Table 2 Distribution of obstetrical history and uterine rupture factors for women
with and without a severe outcome
Women without
a severe outcome
(N 261),
N (%)

Women with
a severe outcome
(N 86),
N (%)

Obstetrical characteristics Maternal parity

1
194 (74.3)
2
49 (18.7)
3+
18 (10.0)

61 (70.9)
20 (23.3)
5 (5.8)

Previous vaginal births (non-VBAC)

0
1+
Missing 3

239 (92.3)
20 (7.7)

78 (90.7)
8 (9.4)

Previous VBACs
0
1
2+
Missing 3

237 (91.5)
17 (6.6)
5 (2.9)

77 (89.5)
7 (8.2)
2 (2.3)

Number of previous cesareans

1
2 or 3
Missing

230 (88.5)
30 (11.5)
1

73 (84.9)
13 (15.1)

Labor and delivery characteristics

UR symptoms
Bleeding
Pain
Fetal distress

187
25
77
146

(72.7)
(9.6)
(29.6)
(55.9)

73
18
33
70

(84.9)
(20.9)
(38.8)
(67.4)

Labor stage UR detected

Latent phase 03 cm
Active phase
Second stage
Postpartum after VBAC

37
109
96
18

(14.2)
(41.9)
(15.5)
(2.9)

11
22
31
22

(12.7)
(25.6)
(36.0)
(25.6)

Extrusion
Complete
Partial

11 (3.8)
63 (24.1)

24 (28.2)
20 (24.1)

Extension of rupture
Into uterus or cervix
Into arteries, ligament or bladder

87 (33.3)
33 (12.6)

33 (39.3)
32 (38.1)

Abbreviations: UR, uterine rupture; VBAC, vaginal birth after cesarean.

minor ruptures will be discovered among those with a cesarean.

In all, 86% of the severe outcomes among women having a
VBAC were due to maternal bleeding. The placenta was manually
removed in 37% of these women, compared with 25% manual
removals in the non-severe VBAC group (P 0.42).

Severe outcomes from uterine rupture

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841
Table 3 Crude relative risks (RRS) for severe outcomes among women with a
uterine rupture by demographic and clinical factors
Women without
a severe
outcome, N (%)

Women with
a severe
outcome, N (%)

Crude RR with
95% confidence
interval (CI)

Maternal age
<35
X35

194 (74.3)
67 (25.7)

54 (62.8)
32 (37.2)

1.0
1.47 (1.02, 2.13)

Parity
1
X2

194 (74.3)
67 (25.7)

61 (70.9)
25 (29.1)

1.0
1.14 (0.76, 1.70)

Interdelivery interval
p18 months
>18 months

41 (15.7)
220 (84.3)

22 (25.6)
64 (74.4)

1.56 (1.04, 2.32)

1.0

Hospital level
Tertiary center
Larger community
Smaller community

99 (31.9)
95 (56.4)
967 (25.7)

38 (44.2)
31 (36.1)
17 (19.7)

1.0
0.89 (0.59, 1.33)
0.73 (0.44, 1.21)

60 (23.0)
110 (42.2)
91 (34.8)

12 (14.1)
39 (45.9)
34 (40.0)
1

1.0
1.49 (0.85, 2.62)
1.55 (0.87, 2.74)

60 (22.9)

12 (14.0)

1.0

48
40
60
53

(18.4)
(15.3)
(23.0)
(20.8)

27
14
14
19

(31.3)
(16.3)
(16.3)
(22.1)

1.68 (1.09, 2.60)

1.21 (0.70, 2.10)
0.88 (0.50, 1.56)

53
46
45
57

(20.3)
(17.6)
(17.2)
(21.8)

20
19
15
20

(23.3)
(22.1)
(17.4)
(23.3)

1.28 (0.79, 2.08)

1.37 (0.84, 2.23)
1.17 (0.69, 2.00)

Type of labor
Spontaneous
Induced
Augmented
Missing
Oxytocin exposure
No exposure
Hours of oxytocin
14
58
X8
Missing
Oxytocin dose (mU min 1)
18
916
>16
Missing

Women experiencing a severe UR were more likely to have their

infant completely extruded from the uterus, and their rupture was
more likely to extend into surrounding structures (P<0.0001).
Associations between maternal demographic and obstetric risk
factors and severe UR outcome were examined. Maternal age of
X35 years was associated with a 47% increased risk of a severe UR
(see Table 3). Parity (Table 3), gravidity, abortion, race/ethnicity
and payer status were not associated with the study outcome
(data not shown in Table 3). Women with severe outcomes had

a mean age 1.5 years older, 32.9 (s.d. 4.2), than those with a UR
but not a severe outcome, 31.4 (s.d. 4.7). The proportion of women
with comorbid medical conditions was the same in those with
(16%) and without (15%) a severe outcome.
Women with severe outcomes had a mean interdelivery interval
of 35 months (95% CI: 24.9, 40.8) compared with a mean of
40.4 months (95% CI: 36.3, 44.4) for women who did not.
The median and range of intervals was 27 (range of 12 to 180) for
those with a severe outcome and 31 (range 10 to 223) months
for those without (data not shown). Interdelivery intervals of
p18 months increased the risk of severe UR by 56%.
Women in this study delivered in a variety of hospitals, from
smaller community hospitals to academic medical centers.
Whether a woman experiencing a UR had a severe outcome was
unrelated to the type of hospital setting in which she delivered.
Although women with a UR and with diabetes, pregnancy
hypertensive disorders or other chronic conditions were more likely
to deliver at a tertiary center (P 0.003), such a medical history
was not related to having a severe outcome (P 0.83) Adjusting
for medical history did not change the relative risk (RR) estimate
associated with the type of hospital.
Use of medication for either induction or augmentation of
labor was very common, with only 73 of the 347 women (21%)
having completely spontaneous labors. A total of 43% of women
had their labors induced with either prostaglandins alone
(N 11) and/or oxytocin, with another 36% receiving oxytocin
for the augmentation of labor. Although the risk for severe UR
associated with induction or augmentation was B50% higher,
these findings were not statistically significant. The number of
women exposed solely to prostaglandins was too small to provide
precise RRs, but analysis of oxytocin alone for induction and
augmentation had nearly the same results as those for type of labor
in Table 3. On examining the hours and dose of oxytocin, only one
finding was significantFwomen had a 67% increased risk of a
severe UR in the first 4 h of oxytocin infusion. Investigation of
possible identifying demographic or obstetrical history risk factors
in this group of women rupturing early only revealed that the
presence of a previous VBAC was strongly protective (P 0.03).
When oxytocin used for induction versus augmentation was
examined, this finding was only significant among those induced
with oxytocin. Among those induced, compared with women with
>8 h of exposure, the risk of a severe outcome was 2.5 times as
much for oxytocin used in the first 4 h (unadjusted RR 2.56;
95% CI: 1.39, 4.70). This risk persisted when those exposed to
prostaglandins were removed (unadjusted RR 2.29; 95% CI:
0.12, 4.69).
Discussion
This study represents the largest population-based data set to
date of validated URs occurring in a wide range of hospitals from
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small community hospitals to tertiary centers. It is also the only

study to follow women for re-hospitalization through 6 weeks
postpartum and infants for documented morbidities until
discharged home. This permitted us to identify 5 women
re-admitted and 3 infant deaths beyond 28 days. The medical
record review employed in this study made it possible to confirm
whether a woman met a specific definition of UR, to accurately
classify her exposures and to distinguish women intending
a trial of labor from those intending a repeat cesarean. Reviewing
infant charts also allowed determination of whether infant
outcomes were directly related to the UR or to some other
condition, and the fact that we were able to follow infants even
if transferred to another hospital until discharged home allowed
a longer period of time to assess possible prognosis.
The fact that we did not find a difference in severe outcome by
hospital type is reassuring that hospitals in Massachusetts are well
prepared for an obstetrical emergency like UR. However, these
findings may not be generalizable to geographically larger states
that do not have as good a dispersion of tertiary care hospitals for
rapid transfer or perinatal licensure regulations that require close
obstetrical and neonatal interaction between tertiary centers and
community hospitals.10
The definition for severe maternal outcome of this study reflects
the management-based group diagnoses for near-miss mortality
suggested by the World Health Organization.11 Additionally, the
Massachusetts Maternal Mortality and Morbidity Review Committee,
for counseling purposes, wanted a more conservative estimate of
severity for mother and infant that would reflect the range of less
than ideal outcomes caused by UR. Maternal morbidity in this
study is similar to that of two other population-based studies that
detailed maternal morbidity from UR, one from Nova Scotia, which
identified 18 complete ruptures (using a definition similar to the
one used here),5 and one from the Netherlands, which had 91
symptomatic ruptures among women with a trial of labor.6
Hysterectomy rates in those studies were similar (5.6% and 4.1%,
respectively) to the 5.7% rate found in the present study. The rate of
maternal transfusion in this study (13%) was lower than those
reported in Nova Scotia (44%) and the Netherlands (19%). These
differences may be because of different transfusion guidelines
in these countries.
Three previous studies have detailed perinatal outcomes
from UR: the two studies just mentioned, and a US multicenter
prospective cohort study that identified 114 URs in term
pregnancies.2 The present study had 10 perinatal deaths, yielding a
perinatal mortality rate of 2.9% compared with the perinatal
mortality rate among women without TOLAC of 2.6%. This rate is
lower than the 11% perinatal mortality rate found in the nonAmerican studies, but is slightly higher than the 1.8% rate found in
the US study. The two non-American studies included preterm
infants, which may account for some of the differences. The one
percentage point higher rate found in our study compared with the
Journal of Perinatology

multicenter study might be explained by the fact that infants in the

present study were followed beyond 28 days. The present studys
rate of hypoxic-ischemic encephalopathy and/or seizures was 2.9%,
half that found in the multicenter US study. The rate of umbilical
cord pH <7 was 27%, similar to the multicenter study but
considerably higher than the 10% rate found in the Netherlands
study.
Although other studies that showed oxytocin use increased the
risk of UR,12,13 this study did not find that oxytocin exposure
increased the risk of having a severe outcome from a UR. However,
severe outcomes were more likely to occur during the first 4 h
of oxytocin used for induction. This could indicate that some
women have weaker scars that will rupture with a lesser amount
of total uterine force and these are more likely to result in larger,
more sudden URs with more severe outcomes.
Maternal age of >35 years has been identified as a risk
factor for UR following a TOL.14,15 The present study found that
older women who experience a UR were somewhat more likely
to have a severe outcome. In addition, several studies have
identified short interdelivery intervals of <6, 18 or 24 months as
risk factors for UR.1618 In this study, women with interdelivery
intervals of p18 months had a 60% increased risk of a severe
outcome related to UR. This information may provide obstetric
providers with even more motivation to counsel women who
have had a cesarean to postpone a subsequent pregnancy for more
than 1 year.
Study limitations include reliance on hospital discharge
coding for initial identification of URs. We have no way of verifying
that we identified all cases of UR. Undoubtedly, many silent URs
were missed among women with a successful VBAC who had no
complications, biasing the results toward a higher proportion of
severe outcomes among women with a VBAC. Approximately onethird of the medical records were missing some elements, such as
the prenatal record (most common), nursing or provider progress
notes during labor or laboratory values. However, missing data
were equally distributed between those with and without a severe
outcome.
This study suggests that among the small percentage of
women who experience a UR after a TOLAC (0.3 to 0.7%),1,2 one
in four women will experience a severe outcome for themselves
or their infants. However, our data show a 6% baseline risk of
a severe outcome among women not undergoing TOLAC, resulting
in an actual increased risk of 19% among those with TOLAC.
Assuming the more conservative 0.7% UR rate among term women
with a TOLAC found in the US multicenter trial,2 the overall
risk that a trial of labor will result in a UR that causes
a severe maternal or infant outcome of any kind is estimated to
be <1.3 in 1000. This risk should be balanced against that of
elective cesarean that, when done before 39 weeks, has some severe
neonatal outcomes: respiratory distress syndrome (9/1000) or need
for mechanical ventilation (4/1000)19 and the long-term maternal

Severe outcomes from uterine rupture

MK Barger et al

843

risks associated with increased placental problems in subsequent

pregnancies.1
Conflict of interest
The authors declare no conflict of interest.
Acknowledgments
This study was funded in part by Cooperative Agreement #S1012-19/19 between
the Centers for Disease Control and Prevention, the Association of Schools of
Public Health and the Boston University School of Public Health. We thank
members of the MMMRC members and staff for their important contribution to
this study, and Drs Elizabeth Brown, neonatologist, and Gary Krauss, Ob-Gyn, who
assisted in the assessments of relatedness of outcomes, and Timothy Heeren, PhD,
for statistical consultation.

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