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ob.uterine-rupture.v1PRODUCTION
ob.uterine-rupture.v1

Uterine Rupture (complete / incomplete dehiscence)

obstetricsacuteadultpregnancy
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Acute obstetric emergency — full-thickness disruption of uterine wall before or during delivery; spectrum from complete rupture (extrusion of fetal parts / placenta into peritoneal cavity; obstetric catastrophe) to incomplete rupture / dehiscence ("uterine window"; serosa intact; often asymptomatic intraoperative finding). Partition by VBAC status (TOLAC / primary unscarred / planned repeat cesarean) + prior incision type (LTCS / classical / T-incision / prior rupture / myomectomy) + labor status (spontaneous / induced / no labor) + maternal-fetal stability + future-fertility-desired. Distinguishes from abruption (unscarred uterus / placental separation), AFE (intravascular embolic), PAS (placental adherence overlap).

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VBAC status + incision type + labor stage + maternal-fetal stability tier tagged

Patient inputs (22)

Tachypnea > 22 is qSOFA / shock-index component; pregnant baseline ~ 16-22 so > 24 is concerning

Hypoxemia raises suspicion for AFE (mimics rupture — sudden hypoxia + hypotension + DIC) or pulmonary edema with overlap

Category III FHR (sudden bradycardia, prolonged deceleration, sinusoidal) is MOST SENSITIVE rupture marker (~ 70%); drives emergent-cesarean decision

LTCS (acceptable for TOLAC 0.4-0.9% rupture) vs low-vertical (1-2%) vs classical / T-incision / J-incision (4-9%; TOLAC CI) vs prior rupture (6-32% recurrence; TOLAC CI) — strongest single risk factor (ACOG PB 205 2019)

Oxytocin (acceptable with caution; ~ 1.5-2x baseline rupture risk per Landon NEJM 2004 PMID 15598960), PGE2 (relative CI; ~ 2-3x baseline), misoprostol (ABSOLUTELY CONTRAINDICATED), Foley (acceptable; preferred mechanical) (ACOG PB 205 2019)

GA drives delivery threshold + NICU planning; TOLAC typically term but earlier presentations possible

TOLAC = trial of labor; planned repeat cesarean = no labor. Risk profile and management differ entirely

Baseline hemoglobin + serial trend (falling Hgb in TOLAC patient = high suspicion for concealed rupture hemorrhage); platelet count for DIC surveillance

Type + screen on TOLAC admission; crossmatch ≥ 2 units PRBC if rupture suspected or unstable; MTP activation if EBL > 1500 mL (Pacheco SMFM 47 2019 PMID 26348379)

DIC surveillance — fibrinogen < 200 mg/dL in pregnancy is concerning (normal pregnancy fibrinogen 350-650); PT/INR + aPTT prolonged with rupture massive hemorrhage; routes to cryoprecipitate + FFP

Renal function + electrolytes for resuscitation + liver function (HELLP overlap if pre-eclampsia co-present)

Quantifies fetomaternal hemorrhage (FMH); critical for Rh-negative mother RhoGAM dose-adjustment; large FMH suggests significant placental disruption

Confirm fetal viability + placental location (rule out PAS / previa); free intraperitoneal fluid suggests intraperitoneal hemorrhage; non-visualisation does NOT rule out rupture — clinical diagnosis primary

Hypotension is a hemorrhagic-shock flag; concealed intraperitoneal rupture hemorrhage can present with rapid maternal decompensation

Maternal tachycardia > 110 in TOLAC patient is an early shock marker; combined with cessation of contractions = high suspicion for rupture

Rh-negative mother with rupture requires RhoGAM 300 mcg IM within 72 h ± KB dose-adjustment (ACOG PB 181 2017)

< 18 mo from prior cesarean → ~ 2-3x baseline rupture risk (ACOG PB 205 2019)

Prior myomectomy entering cavity, cornual resection, prior rupture — additional rupture risk factors (ACOG PB 205 2019)

PAS (accreta/increta/percreta) increases rupture + hysterectomy risk; MFM + tertiary referral preconception if known PAS (Silver AJOG 2015 PMID 25460838)

EFW > 4000 g and multiple gestation modestly increase rupture risk in TOLAC; informs pretest probability

Lactate > 2 with shock features is a hemorrhagic-shock marker; drives MTP + emergent cesarean decision

Patient preference re: future fertility informs intraoperative repair-vs-hysterectomy decision when both are clinically feasible

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateninguterine_rupture_at_diagnosis_emergent_cesarean
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninguterine_rupture_with_massive_hemorrhage_dic
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningconcealed_rupture_with_fetal_distress
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereuterine_rupture_in_tolac_failed
    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%
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehysterectomy_intraoperative_for_rupture
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecurrent_rupture_history_high_risk_pregnancy
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremisoprostol_contraindicated_in_vbac
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereplacenta_accreta_overlap_with_rupture_risk
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepreconception_counseling_after_rupture_or_classical
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmilduterine_window_or_dehiscence_in_repeat_cesarean
    Uterine "window" or dehiscence (incomplete rupture) identified intraoperatively at repeat cesarean — mild (not a clinical emergency); separation of myometrium with intact serosa; repair at cesarean; risk-stratify future pregnancies (typically permits future cesarean delivery; counsel re: inter-pregnancy interval ≥ 18 mo + careful monitoring)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute uterine rupture — resuscitation + emergent cesarean + DIC + repair-vs-hysterectomy + RhoGAM (ACOG PB 205 2019 + Pacheco SMFM 47 2019)
axis: uterine_rupture_acute_managementstep emergent_cesarean_at_diagnosis - Emergent cesarean at rupture diagnosis (ACOG PB 205 2019 + Landon NEJM 2004 PMID 15598960 — door-to-incision < 18-30 min)
Selected step "Emergent cesarean at rupture diagnosis (ACOG PB 205 2019 + Landon NEJM 2004 PMID 15598960 — door-to-incision < 18-30 min)" — Suspected or confirmed uterine rupture in TOLAC or any pregnancy — Category III FHR + maternal compromise OR loss of presenting part OR severe breakthrough pain on epidural
  • oxytocin
    first line
    uterotonic
    10-40 IU in 1 L LR or NS post-delivery • IV infusion (peripheral large-bore) • continuous post-delivery
    triggers: post_delivery_atony_or_routine_third_stage_after_rupture_repair
    Atony prevention post-delivery (rupture is major hemorrhage source; ACOG PB 183 2017 uterotonic ladder applies)
    rxcui 7824
  • tranexamic acid
    first line
    antifibrinolytic
    1 g IV over 10 min within 3 h of birth • IV • single dose; may repeat × 1 after 30 min if continued bleeding
    triggers: post_delivery_PPH_after_rupture
    WOMAN trial 2017 — TXA within 3 h reduces mortality from postpartum hemorrhage (PMID 28456509)
    rxcui 10691

outpatient playbook — drug actions (6)

  1. 1. iron repletion if postpartum anemia
    rxcui 24947
    Ferrous sulfate 325 mg PO TID; IV iron if severe anemia (Hgb < 8) or non-tolerant • PO/IV • TID PO or per infusion protocol
    trigger: Postpartum Hgb < 11 g/dL (rupture + hemorrhage often → significant anemia)
    Restore iron stores; reduce fatigue + improve recovery (ACOG general postpartum guidance)
  2. 2. low-dose aspirin for next pregnancy if HTN-driven
    rxcui 1191
    81 mg PO daily starting before 16 wk in next pregnancy • PO • daily preconception + early pregnancy
    trigger: HTN/pre-eclampsia-associated rupture planning next pregnancy
    USPSTF + ACOG 2018 — low-dose aspirin reduces pre-eclampsia + may reduce HTN-driven obstetric complications
  3. 3. contraception
    Per ACOG MEC + patient preference (LARC, COC, POP, DMPA, etc.) • PO/IM/implant/IUD • per agent
    trigger: Patient request + medical eligibility
    Avoid short interpregnancy interval (< 18 mo associated with worse outcomes — rupture risk 2-3x baseline); ACOG MEC
  4. 4. tobacco cessation pharmacotherapy
    Nicotine replacement OR varenicline OR bupropion per USPHS / USPSTF • PO / transdermal / lozenge • per agent
    trigger: Continued tobacco use postpartum
    Smoking is broad obstetric risk factor; cessation strongly indicated
  5. 5. antihypertensive maintenance
    rxcui 6185
    Labetalol, nifedipine ER, methyldopa per ACOG (compatible with breastfeeding) • PO • per agent
    trigger: Chronic HTN postpartum requiring control
    ACOG PB 203 2019 chronic hypertension in pregnancy guidance (extends to postpartum + breastfeeding compatibility)
  6. 6. influenza + COVID + Tdap vaccines per ACIP
    Per ACIP • IM • per schedule
    trigger: Postpartum
    Standard ACIP recommendations (vaccines are CVX-coded, no single stable RxNorm rxcui — see 2026-05-25 verification)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Uterine Rupture (complete / incomplete dehiscence)** (ob.uterine-rupture.v1).
Phenotype framing: Placental abruption (unscarred uterus / placental separation; painful bleeding common to both — abruption is in unscarred uterus, rupture is in scarred uterus / myometrial disruption), amniotic fluid embolism (sudden hypoxia + hypotension + DIC at delivery; intravascular embolic vs mechanical rupture; can co-present), pulmonary embolism (sudden hypoxia ± hypotension; no uterine signs), placenta accreta spectrum (placental adherence + rupture overlap; intraoperative finding), surgical emergencies (appendicitis, cholecystitis — typically less acute), eclamptic seizure (HTN + proteinuria; tonic-clonic).
Scope: Acute obstetric emergency — full-thickness disruption of uterine wall before or during delivery; spectrum from complete rupture (extrusion of fetal parts / placenta into peritoneal cavity; obstetric catastrophe) to incomplete rupture / dehiscence ("uterine window"; serosa intact; often asymptomatic intraoperative finding). Partition by VBAC status (TOLAC / primary unscarred / planned repeat cesarean) + prior incision type (LTCS / classical / T-incision / prior rupture / myomectomy) + labor status (spontaneous / induced / no labor) + maternal-fetal stability + future-fertility-desired. Distinguishes from abruption (unscarred uterus / placental separation), AFE (intravascular embolic), PAS (placental adherence overlap).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute uterine rupture — resuscitation + emergent cesarean + DIC + repair-vs-hysterectomy + RhoGAM (ACOG PB 205 2019 + Pacheco SMFM 47 2019)** — step "Emergent cesarean at rupture diagnosis (ACOG PB 205 2019 + Landon NEJM 2004 PMID 15598960 — door-to-incision < 18-30 min)".
1. oxytocin 10-40 IU in 1 L LR or NS post-delivery IV infusion (peripheral large-bore) continuous post-delivery (uterotonic, first line) — Atony prevention post-delivery (rupture is major hemorrhage source; ACOG PB 183 2017 uterotonic ladder applies)
2. 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 (antifibrinolytic, first line) — WOMAN trial 2017 — TXA within 3 h reduces mortality from postpartum hemorrhage (PMID 28456509)

Setting playbook (outpatient) — Routine postpartum 6-wk 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 + addiction medicine if substance use + IPV referral if trauma-related + smoking cessation + HTN surveillance + mental health screen (EPDS + PCL-5 for peripartum PTSD given catastrophic event) + immunization audit + newborn outpatient peds 24-48 h post-discharge with HIE-cooling follow-up + developmental tracking for first year
3. iron repletion if postpartum anemia Ferrous sulfate 325 mg PO TID; IV iron if severe anemia (Hgb < 8) or non-tolerant PO/IV TID PO or per infusion protocol — Postpartum Hgb < 11 g/dL (rupture + hemorrhage often → significant anemia) (Restore iron stores; reduce fatigue + improve recovery (ACOG general postpartum guidance))
4. low-dose aspirin for next pregnancy if HTN-driven 81 mg PO daily starting before 16 wk in next pregnancy PO daily preconception + early pregnancy — HTN/pre-eclampsia-associated rupture planning next pregnancy (USPSTF + ACOG 2018 — low-dose aspirin reduces pre-eclampsia + may reduce HTN-driven obstetric complications)
5. contraception Per ACOG MEC + patient preference (LARC, COC, POP, DMPA, etc.) PO/IM/implant/IUD per agent — Patient request + medical eligibility (Avoid short interpregnancy interval (< 18 mo associated with worse outcomes — rupture risk 2-3x baseline); ACOG MEC)
6. tobacco cessation pharmacotherapy Nicotine replacement OR varenicline OR bupropion per USPHS / USPSTF PO / transdermal / lozenge per agent — Continued tobacco use postpartum (Smoking is broad obstetric risk factor; cessation strongly indicated)
7. antihypertensive maintenance Labetalol, nifedipine ER, methyldopa per ACOG (compatible with breastfeeding) PO per agent — Chronic HTN postpartum requiring control (ACOG PB 203 2019 chronic hypertension in pregnancy guidance (extends to postpartum + breastfeeding compatibility))
8. influenza + COVID + Tdap vaccines per ACIP Per ACIP IM per schedule — Postpartum (Standard ACIP recommendations (vaccines are CVX-coded, no single stable RxNorm rxcui — see 2026-05-25 verification))

Non-pharmacologic actions:
- Mental health counseling / therapy if EPDS ≥ 10 or PCL-5 elevated — rupture is catastrophic event; PTSD risk significant
- Lactation continued support if breastfeeding (compatible with all rupture-related medications per LactMed)
- Postpartum exercise progression per ACOG; 6-wk surgical recovery if hysterectomy / repair
- Future-pregnancy preconception counseling — NO TOLAC; elective cesarean 36-37 wk; encourage 18+ mo interpregnancy interval; optimize maternal health (HTN, weight, smoking, substance use); close 1st-trimester surveillance + MFM
- Pediatric follow-up coordination for high-risk newborn — 24-48 h post-discharge peds visit, then 1 wk + 1 mo developmental + immunization tracking; HIE-cooling follow-up if applicable
- Addiction medicine + IPV social-work support continued
- Thrombophilia / PAS workup if recurrent rupture or PAS overlap
- Document rupture event clearly in chart with future-pregnancy planning summary for transfer of care

AVOID / contraindication checks:
- Misoprostol absolutely contraindicated in vbac tolac (ACOG PB 205 2019)
- No tolac after prior classical or T incision or prior rupture (ACOG PB 205 2019)
- Door to incision lt 30 min for rupture in tolac (ACOG PB 205 2019 + Landon NEJM 2004 PMID 15598960)
- Methylergonovine contraindicated in hypertension or preeclampsia (ACOG PB 183 2017)
- Carboprost contraindicated in asthma (ACOG PB 183 2017)
- NSAIDs avoid antepartum PDA constriction and bleeding (ACOG general guidance)
- Kleihauer betke required for Rh negative mother RhoGAM dose adjustment (ACOG PB 181 2017)
- Massive transfusion 1to1to1 PRBC FFP platelets with cryo for fibrinogen lt 200 (Pacheco SMFM 47 2019 PMID 26348379)
- Tranexamic acid within 3 hours of birth only (WOMAN 2017 PMID 28456509)
- Elective cesarean 36 37wk for next pregnancy after rupture or classical incision (ACOG PB 205 2019)

Monitoring

Regimen monitoring:
- Maternal vitals q5-15 min while bleeding; q1 h once stable; q4 h ≥ 24 h post-delivery
- Continuous EFM until delivery (Category I/II/III interpretation)
- Serial Hgb + coag panel q1-2 h while active bleeding; q4-6 h while stabilising
- Fibrinogen target ≥ 200 mg/dL — cryoprecipitate replacement if below
- Platelet target > 50K intrapartum; > 100K if active hemorrhage
- Urine output ≥ 0.5 mL/kg/h
- Lactate trend (≥ 2 with shock features → escalate)
- Kleihauer-Betke for Rh-negative mother — RhoGAM dose-adjustment per result
- Fundal tone q15 min × 2 h then q1 h × 4 h postpartum (atony surveillance — rupture is major hemorrhage source)
- Wound check post-cesarean / post-hysterectomy
- Newborn handoff: rupture + GA + sustained hypoxia documentation → peds / neonatology / NICU; cooling protocol if HIE indicated within 6 h

Setting (outpatient) monitoring:
- 6-wk postpartum visit; additional visit at 1-2 wk if cesarean / hysterectomy wound concern
- Newborn outpatient peds at 24-48 h then 1 wk then 1 mo; HIE-cooling follow-up at 3 + 6 + 12 mo if applicable
- Maternal mental health re-screen at 6 wk + 3 mo + 6 mo (catastrophic event; PTSD risk)
- Future-pregnancy preconception visit when contemplated — MFM mandatory
- Tobacco cessation follow-up at each visit

Follow-up plan: 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.
- Close-out criterion: Postpartum visit complete; future-pregnancy counseling delivered with no-TOLAC + elective cesarean 36-37 wk plan; addiction / IPV / HTN referrals placed; newborn high-risk followup arranged

Monitoring phase: Intrapartum / intraoperative: continuous EFM until delivery, maternal vitals q5-15 min, A-line if unstable, serial Hgb + coag q1-2 h while active, fluid balance. Postpartum: vitals q15 min × 2 h then q1 h × 4 h then q4 h × 24 h, fundal tone q15 min × 2 h then q1 h × 4 h (atony surveillance), lochia + uterine tenderness, repeat CBC + coag q4-6 h until stable, urine output, mental status, wound check. ICU: continuous arterial line + central venous catheter, lactate q2-4 h, daily SOFA + cultures, CAM-ICU, VTE prophylaxis once stable.

Disposition

Current setting: outpatient — Routine postpartum 6-wk 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 + addiction medicine if substance use + IPV referral if trauma-related + smoking cessation + HTN surveillance + mental health screen (EPDS + PCL-5 for peripartum PTSD given catastrophic event) + immunization audit + newborn outpatient peds 24-48 h post-discharge with HIE-cooling follow-up + developmental tracking for first year

Disposition criteria:
- Resolution: 6-wk postpartum visit complete, mental health stable, contraception in place, immunizations up to date, substance use / IPV / HTN follow-ups arranged, newborn developmental tracking ongoing → discharge from rupture-specific surveillance back to routine primary care + preconception planning with MFM referral for next pregnancy (no-TOLAC + elective cesarean 36-37 wk)

Escalation triggers (move to higher acuity):
- 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

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] 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] 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

Citations

- 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) [PMID:15598960](https://pubmed.ncbi.nlm.nih.gov/15598960/)
- Cited evidence (PMID 14990414) [PMID:14990414](https://pubmed.ncbi.nlm.nih.gov/14990414/)
- Cited evidence (PMID 26348379) [PMID:26348379](https://pubmed.ncbi.nlm.nih.gov/26348379/)
- Cited evidence (PMID 28456509) [PMID:28456509](https://pubmed.ncbi.nlm.nih.gov/28456509/)
- Cited evidence (PMID 25460838) [PMID:25460838](https://pubmed.ncbi.nlm.nih.gov/25460838/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:15598960
  • Cited evidence (PMID 14990414) — PMID:14990414
  • Cited evidence (PMID 26348379) — PMID:26348379
  • Cited evidence (PMID 28456509) — PMID:28456509
  • Cited evidence (PMID 25460838) — PMID:25460838