Uterine Rupture Prevention

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Preventing Uterine Rupture — Before It Becomes an Emergency

Most of the work of preventing uterine rupture happens long before a woman is in labour — at the booking visit, in the counselling conversation about mode of delivery, and in how carefully labour is monitored. This guide focuses on that upstream work. For recognizing and managing rupture once it's happening, see our companion Uterine Rupture — Recognition & Emergency Management guide.

🎯 AT A GLANCE — THE PREVENTION FRAMEWORK

Prevention operates on three levels: antenatal risk identification, careful labour management, and systems-level readiness at the delivery facility

Almost every major risk factor for rupture is identifiable at or before booking — this is not a problem that announces itself only in the labour room

GREEN: no identified risk factors — standard antenatal and intrapartum care

AMBER: a known risk factor present (e.g., one prior low transverse caesarean) — needs individualized counselling and a documented labour plan

RED: a high-risk scar type or a strong contraindication to labour — plan the mode of delivery in advance, well before labour onset

📋 ANTENATAL RISK IDENTIFICATION — ASK EARLY

Document any prior uterine surgery in detail at booking — incision type (classical, low transverse, or unknown), indication, and any noted complications

Note the number of prior caesareans — risk rises with each additional scar

Ask about interpregnancy interval — an interval shorter than 18–24 months since the last caesarean raises risk and is worth discussing for future spacing too

Ask specifically about prior uterine rupture, myomectomy (and whether the cavity was entered), or known uterine anomalies

If the prior incision type genuinely can't be confirmed (records unavailable, delivered elsewhere), it's safest to counsel and manage the pregnancy as higher-risk rather than assume a low transverse scar.

✅ CAREFUL TOLAC/VBAC CANDIDATE SELECTION

Best candidates: a single prior low transverse caesarean, no other uterine scars, an adequate pelvis, and ideally spontaneous labour

Favourable signs: a prior vaginal delivery — especially a prior successful VBAC — and a favourable cervix at admission

Have a genuine shared decision-making conversation — discuss the real (low) absolute rupture risk alongside the benefits of avoiding another major surgery

Avoid offering TOLAC after a prior classical or T-incision caesarean, a prior rupture, a contracted pelvis, or any current contraindication to vaginal birth

🛠️ SAFE LABOUR MANAGEMENT PRACTICES

1

Continuous electronic fetal monitoring throughout a TOLAC labour — the fetal heart is often the earliest warning of a problem

2

Use a partograph diligently in every labouring woman — this catches obstructed labour early, scarred uterus or not

3

Use oxytocin cautiously in VBAC — start low, titrate slowly, and keep a low threshold to stop for hyperstimulation

4

Prefer mechanical methods over prostaglandins for cervical ripening in VBAC where a choice exists

5

Reassess promptly whenever the labour pattern changes unexpectedly — don't wait out a change you can't yet explain

⏸️ STOP AND REASSESS — TOLAC CHECKPOINTS

New or worsening pain, especially suprapubic or scar-related

Any change in the fetal heart rate pattern

Slowing or arrest of labour progress on the partograph

Any of these → stop oxytocin, reassess in person, and involve a senior obstetrician promptly — don't just keep monitoring passively

🏥 SYSTEMS-LEVEL PREVENTION

Offer TOLAC only where immediate emergency caesarean, blood bank, and anaesthesia support genuinely exist — "available in principle" is not the same as "ready within minutes"

For women without access to such a facility, plan the delivery location in advance, not once labour has started

Community awareness of the danger signs of obstructed labour, and timely referral, prevents rupture in unscarred uteri too — this matters as much as any single-patient decision

Consistent partograph training across every birth attendant is itself a system-wide prevention strategy, not just a documentation exercise

Short Interpregnancy Interval

Counsel on spacing for future pregnancies

Individualize the TOLAC decision if under 18 months since the last caesarean

Multiple Prior Caesareans

Some centres still consider TOLAC after two prior low transverse caesareans in select cases

Requires extra caution and senior-level counselling

Unknown Prior Scar Type

Make every reasonable effort to obtain the operative record

If truly unknown, counsel and manage as higher-risk

Grand Multiparity

Monitor labour progress vigilantly even without a scar

Avoid augmentation unless genuinely indicated

Plan Ahead

Decide by 36 Weeks

The mode-of-delivery conversation for a scarred uterus works best as an unhurried discussion well before labour — not a decision made in the middle of contractions.

Document the plan clearly in the antenatal record — it needs to be accessible to whoever is actually on duty at delivery, not just the counselling clinician

Reconfirm the plan at each remaining visit as term approaches

When real uncertainty remains about scar type or risk, default to the more cautious option

Make sure the delivery facility itself is actually equipped for emergency response — the safest plan still depends on system readiness

Reminder: prevention starts at the first antenatal visit, not in the labour room.

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

Clinician-facing summary for structured teaching and counselling; exact TOLAC eligibility criteria and interpregnancy interval thresholds vary by guideline and institution — follow local protocol.