Ruptured Uterus

A uterine rupture is an uncommon pregnancy complication in which wall of the uterus suddenly tears open. With a severe ruptured uterus, the tear goes through all the layers of the uterus wall and leaves a hole through which the baby can actually come out. Uterine rupture is an extremely dangerous event that may have significant consequences for both baby and mother.

Uterine rupture occurs in less than 1% (0.07%) of all pregnancies, making one of the least common pregnancy complications. Uterine ruptures often occur at the site of a scar line from a prior C-section. This increased risk of uterine rupture is the primary reason why attempting a vaginal delivery after a prior C-section (VBAC) is considered high risk. Uterine rupture most often occurs during labor but it can also occur earlier during pregnancy.

Symptoms of Uterine Rupture

The signs and physical symptoms of a uterine rupture tend to vary based on when the rupture occurs, the location of the rupture and the extent of the tear. Uterine ruptures occurring along the scar tissue from a prior C-section are generally less intense and result in less dramatic symptoms compared to a spontaneous rupture of an unscarred uterus. In fact, it is widely accepted in the medical community that a uterine scar and the use of uterotonic agents for induction are the most important risk factors identified for uterine rupture.

The classic first sign of a uterine rupture is often said to be abdominal pain, particularly when there is an epidural block in place. But many medical experts push back on the notion of abdominal pain as a symptom. Why? Because abdominal pain is the hallmark of any normal labor. So, arguably, this symptom simply reflects partial pain relief by the epidural analgesic threshold of the epidural block.

The fetal monitor can be helpful in picking up a concern about uterine rupture. The fetal tracing may indicate that a uterine rupture is taking place. Prolonged deceleration of the fetal heart rate is the most consistent finding in cases of uterine rupture.

The principal clinical symptoms of uterine rupture also include:

• Sudden fetal duress (abnormal fetal heart rate)
• Drop in uterine pressure
• Slower and less intense contractions with pain in between
• Recession of the baby’s head back into the birth canal
• Excessive bleeding and maternal shock

The problem with clinically diagnosing uterine rupture is that these primary symptoms are often caused by other obstetrical complications or events. Continued fetal heart rate deceleration and/or prolonged fetal bradycardia is often the only indication of uterine rupture. This type of fetal distress occurs in approximately 79-80% of all cases of uterine rupture. Abdominal pain has been found to be a much less reliable indicator, occurring in only about 5% of uterine rupture cases.

Diagnosing Uterine Rupture

When uterine rupture occurs during labor and delivery, there is an extremely short window of time for doctors to respond to avoid injury to the baby. This means there is no time to perform an ultrasound or any other diagnostic imaging scan or another diagnostic test. Uterine rupture has to be diagnosed quickly based on clinical symptoms alone. Ultrasound imaging does have some application in evaluating the likelihood that scar tissue from a prior C-section will result in uterine rupture.

Treatment & Management of Uterine Rupture

The most important factors in the treatment and management of uterine rupture are (a) timely recognition and a presumptive diagnosis of the rupture; and (b) immediate intervention to deliver the baby as quickly as possible. As soon as doctors even suspect uterine rupture, they must immediately stabilize the mother and then try to deliver the baby as fast as possible. According to various studies, once rupture of the uterus occurs doctors will only have between 10-35 minutes to successfully respond to avoid serious fetal injury or death. Intervention almost always involves an emergency C-section delivery.

Once the baby is successfully delivered via C-section, doctors will need to surgically repair the mother’s torn uterus. In some cases the uterine rupture may trigger major blood loss requiring doctors to perform an emergency hysterectomy (removal of the uterus) following the C-section. This is more likely when the uterus tear is longitudinal as opposed to transverse. Around 5-13% of women will require a hysterectomy after a uterine rupture.

Sometimes, the solution to a developing uterine rupture is to turn off the Pitocin (or Cervidil or another stimulant of uterine activity). Pitocin is used to expedite delivery. Overuse of Pitocin in labor is a well-known and documented cause of uterine ruptures. The package insert on Pitocin says as much.

In a fifty-three year review of uterine ruptures and the and risk factors and causes of uterine ruptures, an article published in the American College of Obstetrics and Gynecologists concluded most uterine rupture cases are avoidable. The article states the in the “majority of the cases (58.3%) of uterine rupture were associated with mid-forceps delivery, breech or version extractions, injudicious use of [Pitocin], and prolonged labor. Thus, the majority of cases must be viewed as potentially avoidable.” This study further found that 12.5% uterine ruptures were the result of mistakes doctors and nurses made with Pitocin.

Birth Injuries From Uterine Rupture

A uterine rupture is one of the most catastrophic complications that can occur during childbirth. Once the uterus ruptures the baby is immediately at risk of acute oxygen deprivation. If the fetus or the placenta extrudes through the tear in the uterus wall, an adverse outcome is almost unavoidable. Even if doctors immediately intervene and perform an emergency C-section within 10-30 minutes of diagnosing uterine rupture, this still may not be enough to prevent hypoxia and serious infant brain injury. Fetal death from asphyxia is a serious threat. Approximately 6% of all babies will not survive a uterine rupture. Serious brain injuries such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy are often the result of any delay in responding to uterine rupture.

More Medical Literature

Dimitrova, D., et al. (2022). Risk factors and outcomes associated with type of uterine rupture. Archives of Gynecology and Obstetrics, 1-11.

This study attempted to distinguish complete uterine rupture risk factors from partial uterine rupture risk factors. The researchers found that puerperal complications and multiparity were more common in complete uterine ruptures. They also found that CUR’s risk factors were women who delivered three births or less, a prior vaginal birth, a trial of labor after Caesarean, and oxytocin use. The researchers found that a trial of labor after Caesarean was a complete uterine rupture’s only independent risk factor.

Perdue, M., et al. (2022). First trimester uterine rupture: a case report and systematic review of the literature. American Journal of Obstetrics and Gynecology.

This study intended to look at a first-trimester uterine rupture’s common presentations, risk factors, and management strategies. The researchers concluded uterine ruptures were not uncommon occurrences during the first trimester. However, they recommended that healthcare providers only consider it in patients suffering from an acute abdomen, especially those who previously underwent uterine surgery. The researchers also concluded that diagnosis and management required surgical exploration, hysterectomies were always not necessary, primary uterine repairs were sufficient for over two-thirds of cases, and continuing the pregnancy, while rare, was possible.

Chiossi, G., et al. (2021). Prevalence of uterine rupture among women with one prior low transverse cesarean and women with unscarred uterus undergoing labor induction with PGE2: A systematic review and meta-analysis. PloS one, 16(7).

This study looked at the uterine rupture presence in women with a prior C-section and an unscarred uterus during labor when dinoprostone (PGE2) was used. The researchers found that the uterine rupture rate in these cases was extremely rare.

Sharon, N., et al. (2021). Midgestational pre-labor spontaneous uterine rupture: A Systematic Review. The Journal of Maternal-Fetal & Neonatal Medicine, 1-6.

This study looked at the data on uterine ruptures that occur during the second and early third trimesters in a non-laboring woman. The researchers found that having at least one prior C-section, a prior uterine rupture, a prior uterine incision, a myomectomy, and congenital uterine malformations were associated with midgestational pre-labor spontaneous uterine ruptures. They suggested that spontaneous pre-labor uterine ruptures during the second and early third trimesters coincided with increasing global C-section rates. The researchers recommended that health care providers know of its associated factors, symptoms, and complications.

Hochler, H., et al. (2020). Grandmultiparity, maternal age, and the risk for uterine rupture—A multicenter cohort study. Acta Obstetricia et Gynecologica Scandinavica, 99(2), 267-273.

This study looked at whether grand multiparity was a uterine rupture risk factor in women with no prior C-sections. The researchers found that uterine ruptures were more common in the grand multiparity group than in the multiparity group. However, the uterine rupture rates were similar when controlling for age. They found that advanced age was a risk factor for uterine ruptures instead of grand multiparity.

Al-Zirqi, I., et al. (2019). Maternal outcome after complete uterine rupture, Acta Obstet. Gynecol. Scand., 98(8), 1024-1031.

The study’s purpose was to look at maternal outcomes after a complete rupture. The study showed that women with an unscarred uterus, of older maternal age, who had less than three children, and who suffered a rupture detection after vaginal delivery showed the highest associations with the risk of peripartum hysterectomy after a complete uterine rupture. The study also found, interestingly, that oxytocin has a higher risk for rupture than induction with prostaglandins.

Rottenstreich, M., et al. (2019). Delayed diagnosis of intrapartum uterine rupture – maternal and neonatal consequences. J Matern Fetal Neonatal Med, 34(5), 1-6.

The study underscores that the failure to appreciate uterine rupture symptoms was associated with higher injury and death rates from uterine ruptures.

Kunz, M.K., et al. (2013). Incidence of Uterine Tachysystole in Women Induced with Oxytocin, J Obstet Gynecol Neonatal Nurs, 42(1),12-18.

The study underscores the need for careful titration of Pitocin to avoid a uterine rupture. A later study points out the need to consider body mass in the amount of Pitocin given.

Ofir, K., et al. (2004). Uterine rupture: Differences between a scarred and an unscarred uterus, Am J Obstet Gynecol, 191(2), 425-429.

This study found no meaningful differences between perinatal or maternal death between rupture of a scarred versus an unscarred uterus.

FAQs: Uterine Rupture

Below are answers to the most commonly asked questions and concerns about uterine rupture and related topics.