How Predictive is CTG of

Scar Rupture in VBAC?

Varsha Jain and Ann Daly

Birmingham Women’s Hospital

Aims and Objectives

 Review current evidence re: CTG and

scar rupture in VBAC
 Critically appraise a study
The clinical question

 Does continuous monitoring with CTG

help us to identify scar rupture in vaginal
birth after section?
 Question identified from a morning CTG
meeting
Literature Search
 Sources:
 Cochrane
 Pubmed
 MIDIRS

 Search terms:
 Cardiotocography (MeSH)
 Uterine rupture (MeSH)
Guidelines
 BWH guidelines state:
 Very low risk of scar rupture in planned VBAC
(0.5%)
 Features to identify scar rupture:
 Abnormal CTG
 Severe abdominal pain, esp in between contractions
 Chest pain/SOB/shoulder tip pain
 Acute onset scar tenderness
 Cessation of previously efficient uterine activity
 Maternal tachycardia, hypotension. Shock
 Loss of station of presenting part
 Vaginal bleeding
 Category 1 section & incident form
Risk of augmentation
 Decision to induce should be a consultant
led decision
 Risk of scar rupture in
 Induced – 102 in 100,000 (1.02%)
 Augmented – 87 in 100,000 (0.87%)
 Spontaneous – 36 in 100,000 (0.36%)
Literature Search Results
Three papers identified
1. Diagnostic potential of CTG for silent uterine rupture
Acta Obstet Gynecol Scand 1989 68 (7) 653-6
(3 patients, CTG done, but uterine rupture not identified until
section)

2. A ten year review of uterine rupture in modern obstetric practice

Ann Acad Med Singapore 1995 24 (6) 830-5

3. Symptoms and Signs with scar rupture – value of uterine activity

measurements
Aust N Z J Obstet Gynaecol 1992 32 (3) 208-12
Papers selected

2. A ten year review of uterine rupture in modern

obstetric practice Ann Acad Med Singapore 1995 24 (6)
830-5

3. Symptoms and Signs with scar rupture – value of

uterine activity measurements Aust N Z J Obstet Gynaecol
1992 32 (3) 208-12
A ten year review of uterine rupture in
modern obstetric practice
Study details
 Retrospective analysis using theatre records at Kerbau
Hospital, Singapore
 1983 – 1992
 26 cases of uterine rupture or scar dehiscence
 Of the 26, 20 cases had previous LSCS
 Most common presentation (25%) was abnormal CTG
(variable or late decelerations or early decelerations
with other signs of fetal compromise eg m/s liquor)
Symptoms and Signs with scar rupture –
value of uterine activity measurements
Study details
 National University Hospital Singapore
 1985-1990
 24,182 total deliveries
 CS rate 12.5% (3026)
 Previous LSCS 4.2% (1018)
 Of this 70.9% (722) had only one
previous CS and trial of labour
Study Details cont.
 Of the women who had a trial of labour 70%
(506) delivered vaginally
 4 cases of incomplete scar rupture
 Incomplete scar rupture where uterine myometrium was
breached but peritoneum remained intact
 5 cases of complete scar rupture
 Complete scar rupture where both uterine myometrium and
peritoneum were breached
 CTG appearances of fetal distress or sudden
decrease in uterine activity
Study Findings
 No maternal death or severe morbidity
(one bladder tear)
 One fresh stillbirth (hydrocephalus)
 One neonatal death
 All 9 cases had oxytocin infusion
Critical appraisal (CASP)
Was the study type appropriate to answer
the question?
Both studies were retrospective analysis
of labour records – yes this is an
appropriate study to answer this type of
question
Critical appraisal
Were confounding factors accounted for?
 Parity
 Number of previous C/S
 Previous vaginal deliveries
 Size of baby
 Use of oxytocin
 Duration of labour
 Age of mother?
 Ethnicity?
 Any more ….
Will the results help us manage our
patients?
 Useful to look at study results to see how
patients can present
 Useful to see types of CTG changes
 Not so useful as continuous CTG will still
be needed
 Practice in this hospital will not change
based on these studies – a pre-existing
BWH thorough guideline
Conclusion
 Review of current guidelines in relation to
VBAC and scar rupture
 Presented two studies – total of 29 cases
 CTG monitoring is needed as can show
helpful signs
 Need to consider full clinical picture
 Need more recent research and larger
study numbers