Uterine rupture - NYSORA

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Uterine rupture

Learning objectives

  • Description of a uterine rupture
  • Management of a uterine rupture

Definition and mechanisms

  • Uterine rupture refers to a complete division of all three layers of the uterus: the endometrium (inner epithelial layer), myometrium (smooth muscle layer), and perimetrium (serosal outer surface)
  • Typical rupture occurs during labor, but it may occasionally happen earlier in pregnancy
  • The fetus is left without the protection of the uterus, leaving the fetus without oxygen and causing the fetus’s heart rate to slow down
  • Suspect uterine rupture based on a rapid drop in the baby’s heart rate during labor
  • The cardinal sign of uterine rupture is loss of fetal station on a manual vaginal exam
  • The maternal mortality rate is < 1%, fetal mortality rate is between 2-6 %
  • Incomplete rupture:
    • Peritoneum is still intact
  • Complete rupture:
    • All three layers are ruptured
    • The contents of the uterus spill into the peritoneal cavity or the broad ligament
  • Bladder injury is not uncommon with uterine rupture
  • A caesarean section is recommended in women who have had a prior rupture

Signs and symptoms

  • Vaginal bleeding
  • Abdominal pain and tenderness
  • Chest pain, pain between the scapulae, or pain on inspiration
  • Hypovolemic shock
  • Signs associated with fetal oxygenation:
    • Late deceleration
    • Reduced variability
    • Tachycardia
    • Bradycardia
  • Absent fetal heart sounds
  • Cessation of uterine contractions
  • Palpation of the fetus outside the uterus (usually occurs only with a large, complete rupture)

Risk factors

  • History of uterine surgery
  • Previous uterine rupture
  • Uterine trauma
  • Congenital uterine anomalies such as septate uterus or bicornuate uterus
  • Vaginal birth after caesarean section
  • Trauma
  • Cocaine use
  • Stretch uterus (multiples or too much amniotic fluid)
  • A breech position requiring external cephalic version
  • Pronged labor


Major maternal blood loss
A higher risk of Coagulopathy
Longer fetal exposure to hypoxia
Intraventricular hemorrhage
Brain ischemia


  • Laboratory tests:
    • Hemoglobin or hematocrit
    • Coagulation tests (prothrombin time, activated partial thromboplastin time, fibrinogen, thromboelastogram)
  • Ultrasound 
    • To rule out placenta praevia, placental abruption, or spontaneous abortion
    • To support the diagnosis: abnormality in the uterine wall, a hematoma next to hysterotomy scar, free fluid in the peritoneum, anhydramnios or fetal parts outside the uterus


Uterine rupture, maternal hemorrhage, caesarean delivery, neuraxial anesthesia, hysterectomy

Suggested reading

  • Gibbins KJ, Weber T, Holmgren CM, Porter TF, Varner MW, Manuck TA. Maternal and fetal morbidity associated with uterine rupture of the unscarred uterus. Am J Obstet Gynecol. 2015;213(3):382.e1-382.e3826.
  • Plaat F, Shonfeld A. 2015. Major obstetric haemorrhage. BJA Education. 15;4:190-193.
  • Walfish M, Neuman A, Wlody D. 2009. Maternal haemorrhage. BJA:: British Journal of Anaesthesia. 103;1:47-56.
  • Guiliano M, Closset E, Therby D, LeGoueff F, Deruelle P, Subtil D. Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery. Eur J Obstet Gynecol Reprod Biol. 2014;179:130-134.

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