"Ruptured Uterus – Lessons from the Frontline"

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Uterine Rupture — Recognition & Emergency Management

Uterine rupture is a full-thickness tear through the uterine wall and overlying serosa — distinct from a dehiscence, a partial scar separation that doesn't breach the peritoneum and is usually silent and incidental. A true rupture can spill the fetus into the abdominal cavity and cause catastrophic, sometimes concealed, haemorrhage. This is a category 1 emergency — outcome depends on how fast it's recognized and acted on.

🎯 AT A GLANCE — WHO'S AT RISK

Prior uterine surgery is the leading risk factor — a classical (vertical) caesarean carries far higher risk than a prior low transverse caesarean

Also: prior myomectomy (especially if the cavity was entered), prior rupture, grand multiparity, uterine anomalies, short interval since a prior caesarean, or uterine over-distension (multiples, polyhydramnios)

Obstructed, unmonitored labour — with an intact, unscarred uterus — remains a leading cause where timely access to caesarean delivery is limited

GREEN: no prior uterine surgery, no risk factors, normally progressing labour — low background risk

AMBER: prior low transverse caesarean or myomectomy attempting labour — real risk, needs continuous monitoring

RED: prior classical/T-incision caesarean, prior rupture, obstructed labour, or current signs of rupture — labour is contraindicated, or this is an emergency in progress

🔎 RECOGNITION — OFTEN SUBTLE AT FIRST

Sudden, severe, "tearing" abdominal pain that persists between contractions — unlike ordinary labour pain, which eases

Previously efficient contractions suddenly stop, and — critically — the pain of labour may abruptly ease or disappear along with them

This apparent relief is a trap, not good news: a sudden cessation of pain after a period of severe, established labour pain is a classic and ominous sign of rupture — it reflects the uterus no longer contracting effectively, not the situation improving. Don't let it reassure you.

Loss of fetal station on exam — a presenting part that was descending becomes unexpectedly high or mobile

Vaginal bleeding can be minimal even with major haemorrhage — significant bleeding may be entirely concealed within the abdomen

Scar tenderness in a woman attempting VBAC is a real but less reliable sign than the fetal heart rate

Fetal heart rate abnormality — often sudden, severe bradycardia — is frequently the earliest and most sensitive sign. Don't wait for maternal symptoms to appear before acting on it.

🚨 SUSPECT RUPTURE — ACT NOW

Sudden severe abdominal pain that doesn't ease between contractions

A sudden, unexpected easing or disappearance of established labour pain — this is a false relief, not an improvement

Sudden fetal bradycardia or a catastrophic CTG change, especially during a trial of labour after caesarean

Labour that abruptly stops progressing

Maternal tachycardia or hypotension out of proportion to visible vaginal bleeding

Any of the above → call for help immediately and move toward delivery, don't wait to "confirm" further

🛠️ IMMEDIATE ACTIONS

1

Call for help — senior obstetrician, anaesthetist, neonatal team, theatre, blood bank, all at once

2

Stop oxytocin immediately if it's running

3

Two large-bore IV lines; send blood for crossmatch; activate the massive transfusion protocol if needed

4

Proceed directly to emergency laparotomy — this is a crash caesarean, not a "watch and see"

5

Prepare for possible hysterectomy if the uterus can't be safely repaired

🏥 SURGICAL MANAGEMENT

Deliver the baby first — then assess and address the uterine defect

Repair (uterorrhaphy) is often feasible for a clean lower-segment tear, especially if the patient is stable and future fertility is desired

Hysterectomy is needed for extensive rupture, uncontrolled haemorrhage, or when repair isn't feasible — such as extension into the cervix, broad ligament, or major vessels

Carefully assess the bladder and ureters — a lower-segment rupture can extend into them given their close proximity

🗓️ PREVENTION & TOLAC/VBAC COUNSELLING

Offer a trial of labour after caesarean (TOLAC) primarily to women with a single prior low transverse caesarean and no other major risk factors

Avoid TOLAC after a prior classical/T-incision caesarean or a prior rupture

Continuous fetal monitoring is mandatory during TOLAC — the fetal heart is often the earliest warning

TOLAC should only be offered where immediate emergency caesarean capability exists — not where a rapid surgical response isn't available

Use oxytocin cautiously during VBAC induction/augmentation — it raises rupture risk (see our Induction & Augmentation guide)

Prior Classical Caesarean

Highest-risk scar type — can rupture even before labour begins

Planned caesarean before labour onset, not a trial of labour

Obstructed Labour

Can rupture even an unscarred uterus if labour is prolonged and unmonitored

Timely partograph use and referral prevent this

Grand Multiparity

Repeated stretching thins the myometrium over time

Monitor labour progress closely, even without a scar

Prior Myomectomy

Risk depends on whether the endometrial cavity was entered

Individualize mode of delivery with the original operative details in hand

Category 1 Emergency

Deliver Without Delay

30

MINUTES
TYPICAL DECISION-TO-DELIVERY TARGET

Once rupture is suspected, every additional minute raises both the fetal hypoxic risk and the volume of concealed maternal haemorrhage. Resuscitation and surgical preparation happen in parallel, not one after the other.

Move directly to theatre once rupture is suspected — don't wait for confirmatory imaging

Resuscitate and operate at the same time — ongoing fluid or blood transfusion should not delay a crash caesarean

Have anaesthesia and neonatal teams ready before arrival in theatre, not after

Document timings clearly — decision time, incision time, delivery time, and estimated blood loss

Reminder: globally, obstructed labour with delayed access to caesarean remains a leading cause of uterine rupture — real prevention starts with careful labour monitoring and timely referral, long before the emergency itself.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary for structured teaching and emergency drills; exact risk figures and timing targets vary by protocol and setting — follow local institutional guidelines.