The focus of this Quick Fact is how shoulder pain can be a symptom of uterine rupture.
How can an uterine rupture cause shoulder pain?
Internal bleeding from uterine rupture can cause referred pain through the phrenic nerve which can present in the shoulder.
Shoulder pain is sometimes not included in lists of uterine rupture symptoms, but I have seen it cited multiple places (see below) and have had conversations with OBs, nurses, and anesthesiologists who have experienced uterine ruptures with shoulder pain.
I’m also aware of two cases where the uterine rupture diagnosis was delayed because staff was not familiar with the incidence of referred pain.
Anyone who works with birthing women should be aware of the symptoms of uterine rupture including referred pain.
Please note that not every uterine rupture causes shoulder pain and not all shoulder pain is a symptom of uterine rupture.
Where can you learn more?
I discuss uterine rupture – factors, symptoms, rates, and outcomes – at great lengths in my online workshop, “The Truth About VBAC: History, Politics, & Stats”
“APH [brisk antepartum haemorrhage], as in this case, often indicates uterine rupture and may occur in association with shoulder tip pain due to haemoperitoneum.” (Navaratnam, 2011)
“Management of uterine rupture depends on prompt detection and diagnosis. The classic signs (sudden tearing uterine pain, vaginal haemorrhage, cessation of uterine contractions, regression of the fetus) have been shown to be unreliable and frequently absent but any of the following should alert suspicion… Chest or shoulder tip pain and sudden shortness of breath.” (Payne, 2015)
“Signs and symptoms of uterine rupture may include… referred pain in the shoulder (with epidural anesthesia)” (Murry, 2007 p.283)
“Jaw, neck, or shoulder pain can be referred pain from a uterine rupture.” (Murry, 2007, p.76)
“Shoulder pain (Kehr’s sign) is a valuable sign of intraperitoneal blood in subdiaphragmatic region. Even a small amount of blood can cause this symptom, but it is important to realize that it may be 24 h or longer after the bleeding has occurred before blood will track up under the diaphragm, and some cases of acute massive intraperitoneal bleeding may not initially have shoulder pain.” (Augustin, 2014, p. 512)
“Shoulder tip pain may be experienced if significant haemoperitoneum is present, due to irritation of the diaphragm (i.e. referred pain through phrenic nerve).” (Baker, 2015, p.373)
Augustin, G. (2014). Acute abdomen during pregnancy. Switzerland: Springer International Publishing. Retrieved from https://books.google.com/books?id=mq8pBAAAQBAJ
Baker, P. N., McEwan, A. S., Arulkumaran, S., Datta, S. T., Mahmood, T. A., Reid, F., . . . Aiken, C. (2015). Obstetrics: Prepare for the MRCOG: Key articles from the Obstetrics, Gynaecology & Reproductive Medicine journal. Elsevier Ltd. Retrieved from https://books.google.com/books?id=DcqqCgAAQBAJ
Murray, M. (2007). Antepartal and intrapartal fetal monitor. New York, NY: Springer Publishing Company, LLC. Retrieved from https://books.google.com/books?id=_4jYJUGG56cC
Murray, M., & Huelsmann, G. (2008). Labor and delivery nursing: Guide to evidence-based practice. New York, NY: Springer Publishing Company. Retrieved from https://books.google.com/books?id=q22jEEZo7rwC
Navaratnam, K., Ulaganathan, P., Akhtar, M. A., Sharma, S. D., & Davies, M. G. (2011). Posterior uterine rupture causing fetal expulsion into the abdominal cavity: A rare case of neonatal survival. Case Reports in Obstetrics and Gynecology, 2011. Retrieved from http://www.hindawi.com/journals/criog/2011/426127/
Payne, J. (Ed.). (2015, Mar 17). Uterine rupture. Retrieved from Patient: http://patient.info/doctor/Uterine-Rupture
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Jen Kamel is the founder of VBAC Facts, an educational, training and consulting firm. As a nationally recognized VBAC strategist and consumer advocate, she has been invited to present Grand Rounds at hospitals, served as an expert witness in a legal proceeding, and has traveled the country educating hundreds of professionals and highly motivated parents. She speaks at national conferences and has worked as a legislative consultant in various states focusing on midwifery legislation and regulations. She has testified multiple times in front of the California Medical Board and legislative committees on the importance of VBAC access and is a board member for the California Association of Midwives.
Free Report Reveals...
Parents pregnant after a cesarean face so much misinformation about VBAC. As a result, many who are good VBAC candidates are coerced into repeat cesareans. This free report provides quick clarity on 5 uterine rupture myths so you can tell fact from fiction and avoid the bait & switch.