Uterine Rupture

A laboring patient with a prior cesarean suddenly stops having contractions and reports a "tearing" sensation — the fetal heart rate crashes. You have minutes, not hours.

Uterine rupture is a catastrophic tearing of the uterine wall, most commonly at a previous cesarean scar site during a trial of labor after cesarean (TOLAC). The classic presentation is sudden, sharp abdominal pain often described as "something ripped" or "tearing," followed by cessation of contractions — the uterus can no longer contract effectively because its wall integrity is lost. The fetal presenting part may recede (loss of station), and in severe cases with fetal extrusion the nurse may palpate fetal parts through the abdomen. Fetal heart rate shows prolonged bradycardia as placental perfusion is acutely lost. Maternal signs progress to tachycardia, hypotension, and signs of hemorrhagic shock as blood pools intraperitoneally. The priority nursing action is recognizing the triad — sudden pain, loss of contractions, fetal bradycardia — and calling for emergency cesarean delivery immediately. Two large-bore IVs, typed and crossmatched blood, and lateral positioning are initiated simultaneously. Risk is highest with a prior classical (vertical) uterine incision (~4–9% rupture rate) compared with a low transverse scar (~0.5–1%). Complete rupture is a surgical emergency; delay beyond 10–15 minutes dramatically worsens neonatal and maternal outcomes.

Key Distinctions

Don't confuse uterine rupture (contractions stop, sharp ripping pain, fetal parts palpable) with placental abruption (contractions continue, rigid board-like uterus, dark bleeding). Students often associate rupture only with VBAC patients, but it can occur with grand multiparity, oxytocin hyperstimulation, or uterine anomalies. An incomplete (dehiscence) rupture involves separation with the uterine serosa still intact and may present subtly with only FHR changes and mild tenderness — complete rupture communicates with the peritoneal cavity and is the dramatic emergency.

Clinical Pearl

Pain then silence: if a laboring VBAC patient screams in pain and contractions vanish from the monitor, think rupture until proven otherwise.