Learning from maternal deaths due to uterine rupture: review of cases from peri-urban Uganda

BACKGROUND: Maternal deaths from uterine rupture continue to occur globally, with particularly high rates in sub-Saharan Africa. Maternal death reviews have been shown to be an effective part of cohesive strategies to prevent future deaths. OBJECTIVE: This study aimed to conduct maternal death reviews for all deaths following uterine rupture in the study center, to assess preventability, and to synthesize key learning points that may help to prevent future maternal deaths following uterine rupture. STUDY DESIGN: Thorough case reviews of all maternal deaths from 2016 to 2018 at the study center (a national referral hospital in urban Uganda) were conducted by trained multidisciplinary panels of obstetricians and midwives. Medical records of women who died following uterine rupture (n=37, 10.6% of all maternal deaths) were extracted for further analysis. RESULTS: Most maternal deaths due to uterine rupture (36/37, 97%) were preventable, with most having been still potentially preventable after the women reached the study center (24/36, 67%). Obstructed labor was the leading cause of uterine rupture, accounting for 73% (27/37) of cases. Previous cesarean delivery was confirmed in 38% (14/37) of cases. The incidence of grand multiparity was 11% (4/37), and 11% (4/37) were primiparous. Most women (28/37, 76%) died within 24 hours of admission. On arrival at the study center, 19 (51%) were critically ill. Exploratory laparotomy was performed in 54% (20/37) of cases, and a further 35% (13/37) died while awaiting laparotomy. Four women died shortly after arrival at the study center (within 1 hour) and received basic resuscitative treatment; 27% (10/37) of women who died had received antenatal planning or preparation. CONCLUSION: Most deaths due to uterine rupture were preventable. The key lessons that emerged from the reviews were: (1) careful birth preparation and complication awareness for women with known risk factors, (2) early recognition of obstructed labor, (3) close monitoring of obstetrical interventions known to be associated with uterine rupture, and (4) treating incipient or suspected uterine rupture as a time-critical obstetrical emergency. The recommendations emerging from our narrative reviews are suitable for implementation in low-resource obstetrical settings, where high numbers of deaths involving uterine rupture occur.