What is the management of uterine rupture within the golden hour?

Golden Hour Management of Uterine Rupture

When uterine rupture is suspected, proceed directly to emergency laparotomy without delay for additional imaging or stabilization attempts, while simultaneously initiating aggressive fluid resuscitation and activating massive transfusion protocol. 1

Immediate Recognition and Initial Resuscitation (Minutes 0-15)

The cornerstone of survival in uterine rupture is recognizing that this is a surgical emergency requiring immediate operative intervention, not a condition that can be stabilized medically first. 1

Critical First Steps:

• Establish large-bore IV access at minimum two sites immediately upon suspicion 1
• Initiate aggressive crystalloid resuscitation with large volumes—do not wait for hemodynamic collapse 1
• Activate massive transfusion protocol immediately to ensure blood products are readily available 1
• Maintain high index of suspicion with fetal bradycardia or distress as the most common and often earliest clinical sign 2, 3

Clinical Presentation to Recognize:

• Abdominal pain and tenderness (87.5% of cases) 4
• Vaginal bleeding (62.5% of cases) 4
• Fetal distress frequently precedes other maternal manifestations 2
• Shock may be present (25% of cases) 4
• Palpable fetal parts through abdominal wall in complete rupture 5

Surgical Management (Minutes 15-60)

The definitive management is emergency laparotomy—imaging and further diagnostic workup will only delay life-saving intervention. 1

Operative Approach:

• Use midline vertical incision for optimal access and visualization to manage hemorrhage and assess rupture extent 1
• Do NOT attempt forced placental removal as this causes profuse hemorrhage 1
• Evaluate for repair versus hysterectomy at time of surgery based on extent of injury, patient stability, and hemostasis 2
• Repair is reasonable in selected cases, particularly in younger patients desiring future fertility 2

Intraoperative Priorities:

• Control maternal hemorrhage as primary objective 1
• Deliver infant promptly 3
• Assess extent of uterine damage and involvement of adjacent structures 1
• Replace blood products aggressively—disseminated intravascular coagulation can complicate uterine rupture 6

Critical Pitfalls to Avoid

The most dangerous error is delaying surgery for additional imaging, further resuscitation attempts, or diagnostic confirmation. 1 Other critical mistakes include:

• Inadequate preparation without multidisciplinary team and appropriate equipment readily available 1
• Attempting forced placental removal leading to uncontrolled hemorrhage 1
• Underestimating fluid and blood product requirements 1
• Failing to recognize incomplete rupture during cesarean section for obstructed labor 4

Immediate Postoperative Vigilance (First 24 Hours)

Maintain low threshold for reoperation if ongoing bleeding is suspected 1

Monitor for Complications:

• Ongoing hemorrhage requiring return to operating room 1
• Renal failure from hypoperfusion 1
• Liver failure 1
• Infection and sepsis (major cause of maternal mortality) 4
• Unrecognized ureteral, bladder, or bowel injury 1
• Pulmonary edema from massive fluid resuscitation 1
• Disseminated intravascular coagulation 1, 6

Neonatal Considerations

Fetal mortality is extremely high (87.5% in obstructed labor cases), with most being fresh stillbirths 4. Surviving newborns require:

• Immediate admission to intensive care nursery 3
• Aggressive resuscitation at delivery 3

Future Pregnancy Counseling

Patients must be counseled about significantly increased risks including recurrent cesarean scar pregnancy, placenta accreta spectrum, and repeat uterine rupture in future pregnancies 1. Early pregnancy ultrasound evaluation is mandatory to confirm proper implantation in any future conception 1. For patients who underwent repair rather than hysterectomy, early elective cesarean delivery at approximately 36 weeks after fetal lung maturity assessment is prudent 2.