A Rare Delayed Presentation of Uterine Rupture Following Vaginal Birth After Caesarean (VBAC): A Case Report and Literature Review.

Uterine rupture is a rare and life-threatening obstetric complication that can lead to severe maternal and foetal morbidity and mortality. About 90% of uterine rupture occurs in a scarred uterus, often following a previous caesarean section or uterine surgery. Uterine rupture is the leading cause of maternal and neonatal morbidity in women attempting a trial of labour after a previous caesarean delivery. The rupture rate among women with a prior scar is approximately 0.5-0.7% and increases with the induction of labour and or augmentation. Rupture of an unscarred uterus is very rare, with an incidence of 0.4-0.6 per 10000, but is believed to be considerably higher in developing countries due to delays in recognising obstructed labour and providing early intervention. The sharp rise in caesarean section rates worldwide and the associated risks to maternal health have increased interest in vaginal birth after caesarean section (VBAC) as a safe and effective way to lower caesarean rates. A ruptured uterus presenting several days after a seemingly successful VBAC is very rare and can be challenging to diagnose, as symptoms and signs are non-specific and may be confused with routine puerperal symptoms, resulting in delayed diagnosis and treatment with long-term health consequences. We report the case of a 35-year-old woman with three previous deliveries, who presented to the Emergency Department one week after a seemingly successful VBAC with complaints of mild vaginal bleeding, lower abdominal pain, and back pain resembling labour pain. Her first pregnancy resulted in a normal vaginal delivery followed by a caesarean section for maternal requests. She was considered a suitable candidate for VBAC due to her prior term normal delivery and, therefore, presumed to have an adequate pelvis given the size of the index foetus. Her labour onset was spontaneous, and her delivery and postpartum period were uncomplicated. She was discharged 24 hours after delivery. On examination, she was afebrile and hemodynamically stable. A pelvic ultrasound revealed a ruptured caesarean section scar surrounded by haematoma, which was confirmed by a computed tomography (CT) pelvis. Following discussion of the clinical problem and management options, she opted for surgical management, and she underwent laparotomy and repair of the ruptured scar. Her postoperative recovery was uneventful, and she was discharged within 24 hours. The increased focus on VBAC as a safe and effective method to lower the rising caesarean section rate has led to more cases of ruptured uterus, usually during labour and delivery. Ruptured uterus presenting several days after what appears to be a successful VBAC is rare, but this is likely to change with the growing VBAC rate. A high level of suspicion is necessary to prevent delayed diagnosis and management, which could affect long-term health outcomes.