Uterine Rupture

Activate obstetric hemorrhage and urgent laparotomy pathways immediately. The operative priority is expeditious neonatal delivery to reduce hypoxic injury and maternal blood loss. When urgency precludes routine preparation, general endotracheal anesthesia and rapid abdominal preparation may be necessary; administer antibiotic prophylaxis when feasible, including after delivery if preincision dosing would delay delivery. ajogajogSurgical management of complex cesarean delivery

Simultaneously prepare for hemorrhagic shock: obtain large-bore intravenous access, send blood for transfusion preparation, and activate a massive transfusion protocol when hemorrhage is substantial or anticipated. Uterine rupture is associated with hemoperitoneum, hemorrhagic shock, emergent peripartum hysterectomy, and fetal or neonatal hypoxic injury or death. ajogajogSurgical management of complex cesarean delivery

At entry, prioritize delivery over extensive adhesiolysis. Divide only adhesions that prevent fetal delivery, then inspect the uterus, broad ligaments, bladder region, and other maternal anatomy for extension or associated injury; secure bleeding and repair identified injuries. ajogajogSurgical management of complex cesarean delivery

A clinically consequential uterine rupture is a full-thickness disruption, commonly occurring through a preexisting hysterotomy area weakened by myometrial dehiscence or thinning under contractile tension. The amniotic sac or uterine contents may become exposed to the abdominal cavity; in severe rupture, the fetus or placenta may be expelled into the abdomen. ajogajogSurgical management of complex cesarean delivery

Document the rupture site, extent, tissue quality, associated hemorrhage, and involvement of adjacent structures before selecting repair or hysterectomy. Uterine preservation is reasonable only when the defect can be safely reapproximated and bleeding is controllable; inability to safely repair or excessive bleeding is an indication for hysterectomy. ajogajogSurgical management of complex cesarean delivery

Registry-based studies can misclassify partial ruptures or uterine dehiscence as rupture when diagnosis relies on ICD coding. In clinical care, base management on operative anatomy and maternal-fetal consequences rather than coding terminology alone. NatureNatureUterine rupture risk during trial of labor after one cesarean in a population-based cohort study of induction method and labor management | Scientific Reports

For patients considering TOLAC, discuss both the chance of vaginal delivery and scar-related risk. Large studies summarized in a review report vaginal delivery success rates of 60% to 77% among TOLAC populations; the same review reports uterine rupture in 1.59% of patients attempting VBAC after two prior cesareans. ScienceDirectScienceDirect11 Uterine scar rupture - Prediction, prevention, diagnosis, and ...

Labor management is a modifiable risk domain. Third-trimester misoprostol should not be used for induction or cervical ripening in a patient with a uterine scar; literature citing ACOG guidance recommends against this practice because of reported ruptures. ScienceDirectScienceDirectUterine rupture associated with misoprostol labor induction in women with previous cesarean delivery - ScienceDirect

Induction-related risk estimates require careful interpretation because induction approach, oxytocin exposure, and cervical status affect both labor outcomes and rupture risk. In a cohort summarized in NICE evidence tables, among women with one prior cesarean and no prior vaginal delivery, vaginal birth occurred in 51% of induced labors versus 64.7% of spontaneous labors. nice org uknice org uk[PDF] CG70 Evidence tables - NICE A recent population cohort also notes that unavailable oxytocin dose and duration data limit interpretation of associations between labor management and rupture. NatureNatureUterine rupture risk during trial of labor after one cesarean in a population-based cohort study of induction method and labor management | Scientific Reports

After delivery and uterine assessment, continue systematic inspection for maternal injury and persistent bleeding. Complex cesarean surgical guidance specifies careful inspection of maternal anatomy, control of all bleeding, and repair of identified injuries; transfusion support, including massive transfusion protocol activation, may be required. ajogajogSurgical management of complex cesarean delivery

A minimally invasive approach is not the default acute strategy. A 2025 report proposes laparoscopic repair only for hemodynamically stable patients with minor rupture after spontaneous delivery; this selective approach does not replace emergency laparotomy when urgent delivery, active major hemorrhage, or unstable physiology is present. Wiley+1WileyLaparoscopic repair of uterine rupture after delivery: A comprehensive evaluation of the uterine rupture management, with a proposal surgical method - Pecorella - 2025 - International Journal of Gynecology & Obstetrics - Wiley Online LibraryajogSurgical management of complex cesarean delivery

The operative report should record the anatomic site and extent of the rupture, whether it was full thickness, whether fetal or placental extrusion occurred, repair technique or hysterectomy, estimated hemorrhage, transfusion, and associated bladder or other maternal injury. These findings distinguish a true rupture from lesser scar disruption and provide the data needed for future pregnancy counseling. Nature+1NatureUterine rupture risk during trial of labor after one cesarean in a population-based cohort study of induction method and labor management | Scientific ReportsajogSurgical management of complex cesarean delivery

For patients whose rupture followed a non-cesarean uterine procedure, include the antecedent procedure in discharge documentation. Pregnancy-associated rupture has been reported after hysteroscopic procedures and in the setting of prior laparoscopic myomectomy, where prior surgical details may materially affect future risk assessment. Wolters KluwerWolters KluwerUterine rupture in patients with a history of hysteroscopy... : Medicine