Patient handout

Uterine Rupture (complete / incomplete dehiscence)

PRODUCTION

1. Your condition

This handout is for uterine rupture (complete / incomplete dehiscence). Your care team identified this based on: sudden fetal bradycardia or prolonged deceleration (category iii fhr) in a patient undergoing tolac — most sensitive marker of uterine rupture (~ 70% of cases; ridgeway ajog 2004 pmid 14990414).

Other reasons your team may use this plan: severe, acute abdominal pain breaking through epidural analgesia in tolac — red flag for uterine rupture (acog pb 205 2019); loss of presenting part / change in fetal station on cervical exam during tolac — pathognomonic when present (low sensitivity) (acog pb 205 2019); maternal tachycardia + hypotension + signs of hemorrhagic shock during or after tolac — may reflect concealed intraperitoneal hemorrhage (acog pb 205 2019).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
oxytocin	10-40 IU in 1 L LR or NS post-delivery	IV infusion (peripheral large-bore)	continuous post-delivery	Atony prevention post-delivery (rupture is major hemorrhage source; ACOG PB 183 2017 uterotonic ladder applies)
tranexamic acid	1 g IV over 10 min within 3 h of birth	IV	single dose; may repeat × 1 after 30 min if continued bleeding	WOMAN trial 2017 — TXA within 3 h reduces mortality from postpartum hemorrhage (PMID 28456509)

Plan: Acute uterine rupture — resuscitation + emergent cesarean + DIC + repair-vs-hysterectomy + RhoGAM (ACOG PB 205 2019 + Pacheco SMFM 47 2019)

3. When to call your provider

Contact your care team if any of the following happen:

Postpartum bleeding / persistent uterine tenderness / wound dehiscence / foul lochia → endometritis or retained products / wound infection workup (ED visit)
New mental health crisis (PHQ-9 ≥ 15 or suicidal ideation; PTSD flashbacks) → urgent mental health referral
Newborn high-risk features (persistent feeding issues, neurodevelopmental concerns) → urgent peds visit
IPV resurgence → social work + safety planning + law enforcement coordination per patient consent
Resumed substance use → addiction medicine urgent visit + harm-reduction
Subsequent pregnancy → IMMEDIATE MFM referral + no-TOLAC plan + elective cesarean 36-37 wk

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Suspected or confirmed uterine rupture at diagnosis — life-threatening; EMERGENT CESAREAN (door-to-incision target < 18-30 min per Landon NEJM 2004 PMID 15598960); MTP-ready; do NOT delay for further imaging — bedside US can confirm fetal viability + placental location but treatment cannot wait(life-threatening)
TOLAC complicated by uterine rupture — severe; emergent cesarean + risk-stratify future deliveries; NO TOLAC in subsequent pregnancy per ACOG PB 205 2019; elective cesarean 36-37 wk; recurrence 6-32%
Uterine rupture + maternal massive hemorrhage (EBL > 1500 mL) + DIC features (fibrinogen < 200, platelets < 100, prolonged PT/aPTT, oozing IV sites) — life-threatening; MTP 1:1:1 + cryoprecipitate + FFP + platelets per Pacheco SMFM 47 2019 PMID 26348379; ICU; hysterectomy if uncontrolled hemorrhage despite uterotonics + tamponade + repair attempts(life-threatening)
Intraoperative decision for hysterectomy at rupture surgery — severe; indicated for extensive damage / devitalised edges / hemodynamically unstable / continued bleeding despite repair / PAS overlap / future fertility not desired; preconception MFM for any future pregnancy planning given fertility-loss + scar pattern (ACOG PB 205 2019)
Sudden fetal bradycardia / Category III FHR pattern without other explanation in TOLAC patient + maternal hemodynamic compromise but minimal visible vaginal bleeding — concealed intraperitoneal rupture hemorrhage; life-threatening; EMERGENT SURGICAL exploration regardless of imaging; high index of suspicion required(life-threatening)
Prior uterine rupture in prior pregnancy — severe future-pregnancy risk; recurrence 6-32% (ACOG PB 205 2019); preconception MFM consultation mandatory + NO TOLAC + elective cesarean at 36-37 wk + close 3rd-trimester surveillance (warning signs awareness + frequent visits + early hospital admission if pain or contractions)
Misoprostol administration for cervical ripening in VBAC / TOLAC patient — severe; ABSOLUTELY CONTRAINDICATED per ACOG PB 205 2019; preventable rupture risk; care-quality M&M event if used; alternative agents: oxytocin (acceptable with caution), Foley balloon (acceptable; preferred mechanical), PGE2 (relative contraindication — use with caution)
Placenta accreta / increta / percreta (PAS spectrum) identified preconception or antepartum — severe; increased rupture + hysterectomy risk; MFM + tertiary referral preconception (Silver AJOG 2015 PMID 25460838); planned cesarean hysterectomy with multidisciplinary team at tertiary center 34-36 wk; pre-operative IR consult for prophylactic balloon placement; massive transfusion ready
Patient with prior uterine rupture OR prior classical / T-incision / J-incision cesarean contemplating subsequent pregnancy — severe future-pregnancy risk; elective cesarean 36-37 wk recommended (ACOG PB 205 2019); NO TOLAC; preconception MFM consultation mandatory; close 3rd-trimester surveillance; address modifiable risk factors (HTN, smoking, substance use, inter-pregnancy interval ≥ 18 mo); document plan for transfer of care

5. Follow-up

6-wk postpartum visit + rupture-specific anticipatory guidance: recurrence 6-32% in subsequent pregnancy (ACOG PB 205 2019); preconception MFM mandatory; elective cesarean at 36-37 wk for next pregnancy; NO TOLAC in subsequent pregnancy; close 3rd-trimester surveillance for warning signs; thrombophilia / PAS workup if recurrent; addiction medicine if substance use; IPV referral if trauma-related; smoking cessation; HTN surveillance if HTN-driven; mental health screen (EPDS + PCL-5 for peripartum-PTSD given catastrophic event); contraception counseling; immunization audit; newborn outpatient 24-48 h post-discharge peds visit + HIE-cooling follow-up + developmental tracking for first year if hypoxic exposure.

6. Sources

Guideline: ACOG Practice Bulletin 205 (2019, reaffirmed 2024) — Vaginal Birth After Cesarean Delivery (VBAC) — covers uterine rupture in TOLAC context + ACOG / SMFM joint consensus on TOLAC + Landon MB et al — Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery (MFMU Network, N Engl J Med 2004; 351(25): 2581-2589; PMID 15598960) + Ridgeway JJ et al — Fetal heart rate changes associated with uterine rupture (Am J Obstet Gynecol 2004; 103(3): 506-512; PMID 14990414) + Pacheco LD et al — An update on the use of massive transfusion protocols in obstetrics (Am J Obstet Gynecol 2016; 214(3): 340-344; PMID 26348379) + Silver RM et al — Center of Excellence for Placenta Accreta (Am J Obstet Gynecol 2015; 212(5): 561-568; PMID 25460838) + ACOG PB 181 2017 Anti-D Immunoprophylaxis + ACOG PB 183 2017 Postpartum Hemorrhage + WOMAN trial Shakur 2017 (PMID 28456509) — TXA in PPH (carryover to rupture-delivery PPH)