Uterine rupture !

Uterine rupture is a tear through the wall of the womb in late pregnancy or labour, usually at an old caesarean scar. It is a life-threatening emergency.

Updated 2026-11-01

Structures involved

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Why it happens

What it is

A full-thickness tear of the uterine wall, including the serosa, during pregnancy or labour, usually at the site of a previous caesarean or other uterine scar. It differs from scar dehiscence, in which the serosa stays intact.

Who gets it

Rare in women with an unscarred uterus. Most cases occur in women attempting vaginal birth after a previous caesarean, where the risk is low but real, and the risk is higher after a classical (vertical) uterine incision. In low-resource settings, neglected obstructed labour remains an important cause in unscarred uteri.

Causes

Previous uterine scar: caesarean section (especially classical or T incision), myomectomy entering the cavity
Obstructed labour with an unscarred uterus
Excess uterine stimulation (oxytocin, prostaglandins in a scarred uterus)
Trauma, internal version, forceful fundal pressure
Placenta accreta spectrum invading the myometrium

Risk factors

Previous classical or T-shaped caesarean incision
Trial of labour after caesarean, especially with induction
Short interval since the last caesarean
Grand multiparity
Overdistension: multiple pregnancy, polyhydramnios, macrosomia
Uterine anomalies

Pathophysiology

The weakest point of the uterine wall, usually a scar in the lower segment, gives way under the tension of contractions or obstruction. Blood vessels in the myometrium, including branches of the uterine artery, bleed into the peritoneal cavity or broad ligament, and the fetus and placenta may be extruded into the abdomen, abruptly cutting placental gas exchange.

Classification

Complete rupture: all layers torn, uterine cavity opens into the peritoneal cavity
Incomplete rupture or dehiscence: serosa (visceral peritoneum) intact
Scarred versus unscarred uterus

Symptoms and signs

Sudden abnormal fetal heart rate, most often prolonged bradycardia (the most common sign)
Constant abdominal pain, sometimes a tearing sensation; pain may persist despite epidural
Loss of fetal station on vaginal examination
Vaginal bleeding (may be minor despite major internal bleeding)
Cessation of contractions; fetal parts easily felt through the abdomen
Signs of hypovolaemia: tachycardia, hypotension, shoulder-tip pain

Diagnosis

Clinical: Suspected clinically from fetal heart rate changes plus abdominal pain, bleeding and loss of station in a woman at risk; confirmed at laparotomy. Diagnosis must not delay surgery.
Tests: Blood count, crossmatch and coagulation tests for massive transfusion; continuous fetal monitoring.
Imaging: Not usually performed in the acute setting; ultrasound may show free fluid or the fetus outside the uterus if the woman is stable.

Differential diagnosis

Placental abruption
Umbilical cord prolapse
Other causes of haemoperitoneum (ruptured liver, splenic artery aneurysm)
Amniotic fluid embolism
Uterine inversion (after delivery)

Goal of treatment

Deliver the baby immediately, stop the haemorrhage, restore circulating volume and repair or remove the uterus.

Treatment

Acute: Activate the obstetric haemorrhage protocol: large-bore venous access, crystalloids, blood products and correction of coagulopathy.
Surgical: Emergency laparotomy with delivery of the baby; repair of the tear when feasible and bleeding is controlled.
Surgical: Hysterectomy when the tear is extensive, cannot be repaired or bleeding persists; bladder repair if involved.
Follow-up: Nursing: continuous fetal heart monitoring in labour after caesarean, maternal vital signs, urine output and blood loss; intensive care after surgery.

Complications

Massive haemorrhage, hypovolaemic shock and maternal death
Hysterectomy and loss of fertility
Bladder injury
Fetal hypoxic-ischaemic injury or death
Disseminated intravascular coagulation

Prognosis

Maternal survival is high with rapid surgery and transfusion in hospital, but fetal death or brain injury is common if delivery is delayed. After repair, future pregnancies carry a high recurrence risk and are delivered by planned caesarean.

Prevention

Careful selection and monitoring for trial of labour after caesarean
Avoid prostaglandins for induction in women with a uterine scar
Avoid labour after a classical incision
Partogram use to detect obstructed labour early

Test yourself

Think of the answer, then tap the question to see it.

What is the most common first sign of uterine rupture in labour?

An abnormal fetal heart rate pattern, typically sudden prolonged bradycardia.

What is the main risk factor for uterine rupture?

A previous uterine scar, especially a classical (vertical) caesarean incision.

Which finding on vaginal examination suggests rupture?

Loss of fetal station (the presenting part moves back up).

Which induction agents are avoided in women with a previous caesarean?

Prostaglandins, because they increase the risk of uterine rupture.

What is the treatment of uterine rupture?

Immediate laparotomy with delivery, haemorrhage control and repair or hysterectomy.

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Educational information, not medical advice. For any symptom, see a health professional.

Sources: Uterine Rupture (MSD Manual Professional Edition, 2024); Fetal Monitoring During Labor and Delivery (MSD Manual Professional Edition, 2024).

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Representative model, for educational purposes only.

Lower uterine segment highlighted on the Durgical 3D model