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Obstetrics

Ruptured Uterus

A catastrophic obstetric emergency involving a full-thickness tear through the uterine wall, often occurring during labour, especially in women with previous uterine scars or obstructed labour.

Also known as: Uterine Rupture

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Referral and warning signs

When to refer

IMMEDIATE EMERGENCY REFERRAL/TRANSFER to hospital capable of emergency laparotomy, blood transfusion, intensive care for ALL suspected cases.

Red flags

  • Sudden cessation of contractions
  • Constant severe abdominal pain
  • Maternal shock
  • Fetal bradycardia/distress or absent FHR
  • Loss of station
  • Easily palpable fetal parts abdominally

Signs and symptoms

  • Sudden, severe, constant abdominal pain.
  • Cessation of contractions.
  • Vaginal bleeding (slight or massive).
  • Maternal shock (tachycardia, hypotension) out of proportion to visible bleeding.
  • Fetal distress or absent FHR.
  • Loss of station of presenting part.
  • Easily palpable fetal parts abdominally.
  • Abdominal tenderness/guarding.
  • Change in abdominal contour.

Risk factors

  • Previous C/S scar (esp. classical).
  • Previous uterine surgery (myomectomy).
  • Obstructed labour.
  • Grand multiparity.
  • Improper oxytocic use.
  • Obstetric manoeuvres (versions).
  • Instrumental delivery.
  • Trauma.

Diagnosis

Clinical assessment

High index of suspicion + clinical signs during labour/postpartum (pain, shock, cessation of contractions, fetal distress/death, change in abdo findings).

Investigations

  • Primarily clinical diagnosis in emergency.
  • Ultrasound (limited utility acutely).
  • Confirmation at laparotomy.

Diagnostic criteria

Clinical diagnosis based on signs/symptoms suggesting uterine tear.

Management

Non-pharmacological management

  • EMERGENCY: Call for HELP. ABC resuscitation. 2 large IV lines. Rapid IV fluids. Oxygen. Immediate transfer to Operating Theatre.

Pharmacological treatment

  • Blood Transfusion: Urgent cross-match, transfuse WB/PRBCs + FFP/platelets as needed.
  • Antibiotics: Broad-spectrum IV (Ceftriaxone + Metronidazole).

Monitoring

Continuous maternal vital signs. Monitor blood loss. Prepare for neonatal resuscitation.

Surgical Management

  • Laparotomy: Deliver fetus/placenta. Assess rupture. Uterine Repair (if feasible/stable/desired fertility) OR Hysterectomy (often necessary).

Complications

  • Maternal: Massive haemorrhage, Shock, DIC, Organ damage (bladder/ureter), Infection/Sepsis, Hysterectomy/Infertility, Death.
  • Fetal/Neonatal: Hypoxia/Asphyxia, Brain damage, Stillbirth/Death.

Prevention

  • Judicious oxytocic use.
  • Partograph monitoring (esp. TOLAC).
  • Early management of obstructed labour.
  • Planned repeat C/S for high-risk scars.
  • Avoid inappropriate manoeuvres.

Patient education

  • (Post-event): Explanation, surgery details. Future pregnancy implications (elective C/S needed). Contraception/FP counseling. Emotional support.

Uganda-specific notes

Devastating complication often linked to obstructed labour/previous C/S/oxytocic misuse. High mortality due to delays. Prevention (skilled attendance, partograph) vital.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.4.4

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