Uterine Rupture

Complete or partial disruption of the uterine wall during pregnancy or labor, a catastrophic obstetric emergency carrying high maternal and fetal mortality if not immediately recognized and managed.

The strongest risk factor is a previous cesarean section or other uterine surgery (myomectomy, previous rupture), particularly with a classical (vertical) uterine incision, which carries a substantially higher rupture risk than a lower segment transverse incision.

Other risk factors include obstructed labor (see that entry, a major cause in settings with limited cesarean access), injudicious oxytocin use, grand multiparity, and uterine over-distension (multiple pregnancy, polyhydramnios).

• Sudden, severe abdominal pain, often described as tearing, sometimes with a brief cessation of contractions after previously strong labor
• Sudden, sustained fetal bradycardia or other severe CTG abnormality is frequently the first and most reliable sign, particularly in a trial of labor after cesarean, and should prompt immediate consideration of rupture
• Vaginal bleeding, though this may be minimal despite significant intra-abdominal hemorrhage
• Loss of station of the presenting part (the fetal head, previously engaged, becomes palpable higher or is no longer palpable on vaginal examination) as the fetus extrudes into the abdominal cavity
• Maternal tachycardia, hypotension, and signs of hypovolemic shock, which may be disproportionate to visible blood loss given concealed intraperitoneal hemorrhage
• Scar tenderness in a woman with a previous cesarean section attempting vaginal birth

Primarily clinical, given the need for immediate action; imaging is not used to confirm the diagnosis in the acute setting, since any delay for imaging risks maternal and fetal death.

The combination of sudden fetal bradycardia, severe abdominal pain, and maternal hemodynamic compromise, particularly in a woman with a uterine scar or obstructed labor, should prompt immediate emergency laparotomy without waiting for further confirmatory testing.

• Immediate emergency laparotomy is the definitive management, with delivery of the fetus and repair or, where repair is not feasible or bleeding is uncontrollable, hysterectomy
• Call for senior help immediately: senior obstetrician, senior anesthetist, and theatre team activated as a maximum obstetric emergency
• Aggressive maternal resuscitation as for any major hemorrhage: two large-bore IV access, crossmatched blood, activation of the massive transfusion protocol as needed (see Postpartum Haemorrhage entry for detailed transfusion principles)
• Uterine repair is attempted where the rupture is amenable and future fertility is desired and feasible; hysterectomy is performed where repair is not possible or bleeding cannot otherwise be controlled
• Neonatal resuscitation team present at delivery given the high risk of severe fetal hypoxia
• Counseling regarding future pregnancy: subsequent pregnancies after uterine rupture are managed with planned cesarean delivery, typically before the onset of labor, given the substantially elevated recurrence risk with any subsequent labor

Referral: this is a maximum obstetric emergency requiring immediate senior obstetric, anesthetic, and theatre team activation.