Initial management of uterine rupture with hemodynamic instability should involve fluid resuscitation and stabilization and then urgent delivery (cesarean delivery/exploratory laparotomy). Bedside U/S may be utilized to see if there is a large amount of free fluid/blood in the abdomen, but should not delay management if there is a high suspicion of uterine rupture.
In stable patients (rare if true uterine rupture), a formal ultrasound may be able to determine a uterine wall defect although likely there will be fetal heart rate changes that would indicate delivery before this can be arranged.
High suspicion for uterine rupture should prompt emergency Cesarean section (within 30 minutes)
Urgent cesarean section and exploratory laparotomy
In the cases where there is a high suspicion of uterine rupture with fetal distress and maternal hemodynamic instability, a midline vertical incision usually leads to faster delivery and better visualization for management of bleeding (Please see the portion on Cesarean Section 101 for discussion of different entry methods). The caveat to this is if the surgeon has limited experience with midline vertical incisions, then the method of fastest and safest entry should be use.
In cases where there is an abnormal fetal heart rate in a hemodynamically stable patient, a stat cesarean section should be performed and a pfannenstiel incision may be used. The caveat of this entry method is poor visualization of bleeding. The baby is then usually delivered through the existing uterine defect.
Uterine repair vs. Hysterectomy
The choice for uterine repair versus cesarean hysterectomy depends on:
- Control of bleeding, hemodynamic stability
- Extent of uterine damage
- Desire for future pregnancy
The priority should always be the safety and well-being of the patient.
Please see the module ‘4.5 Management of incision extensions’ for more details on complex surgical repair of the uterus.
Other methods of controlling bleeding
Other methods of controlling bleeding during a uterine rupture, after the baby has been delivered, include:
- Abdominal packing- sponges and towels should be packed into the uterus and abdomen to control bleeding via pressure
- Uterine artery ligation or internal iliac artery ligation
- Other methods of hemostasis like flowseal
- Cesearean hysterectomy – of note, this is usually a subtotal hysterectomy to decrease the risk of ureteric injury.
The baby may require resuscitation after delivery so important to have someone with NRP present. A general anesthetic is also required for this type of delivery due to the potential requirement of hemodynamic support secondary to hemorrhagic hypovolemia and hypovolemic shock. Consulting another surgeon virtually or in person to aid in the surgery is recommended and letting the rest of the team know of a possibly unstable patient is another consideration. . It is important that these resources are coordinated in advance for patients with high risk for uterine rupture to prevent delay in treatment. Clear communication with all health care providers including anesthesiologists, nurses, attending physician and the blood bank for initiating a massive transfusion protocol, if needed, is important for optimizing care.