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Incidence and Predictors of Uterine Rupture with Maternal and Perinatal Outcome: A Cross-sectional Study
MS, Raj Kishore Singh2DCH, MD, Aradhana Singh1,MD, Preeti Bala Singh1MS, Nidhi Singh3MS, Anupama Singh4PhD
*Corresponding author: Aradhana Singh, Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Gorakhpur, Uttar Pradesh, India. aradhanamdobg@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Pipal VR, Singh RK, Singh A, Singh PB, Singh N, Singh A. Incidence and predictors of uterine rupture with maternal and perinatal outcome: A cross-sectional study. Int J Matern Child Health AIDS. 2025;14:e020. doi: 10.25259/IJMA_28_2025
Abstract
Background and Objective:
Although maternal mortality in India has declined significantly due to improved healthcare access and government initiatives, uterine rupture is re-emerging as a serious obstetric complication, largely driven by the rising incidence of cesarean deliveries. This study was conducted to evaluate the incidence, risk factors, and maternal and fetal outcomes of uterine rupture at a tertiary care center in Eastern Uttar Pradesh, India.
Methods:
An observational cross-sectional study was conducted over 12 months (October 2019–September 2020) in the gynecology inpatient department of a tertiary care center. All clinically diagnosed and laparotomy-confirmed cases of uterine rupture were included. Maternal demographics, antenatal and perinatal risk factors, intraoperative findings, and maternal and fetal outcomes were analyzed. The occurrence of uterine rupture during COVID and non-COVID periods was compared using a Z test for proportion. The incidence was calculated from the total number of hospital deliveries during the study.
Results:
Of 3,552 deliveries, 31 cases of uterine rupture were reported, yielding an incidence of 8.7/1,000– markedly higher than the national average. The incidence during the COVID-19 period increased, but was not statistically significant. Previous cesarean section (CS) with unsupervised labor was the leading risk factor. Maternal mortality was 6.45%, and 83.87% of women recovered without major complications. Perinatal mortality was alarmingly high at 96.77%, with only one neonate surviving.
Conclusion and Global Health Implications:
Uterine rupture remains a significant contributor to maternal and perinatal mortality in rural India, particularly due to unsafe labor practices and poor antenatal care. There is an urgent need to strengthen health systems, referral networks, and community education to prevent uterine rupture and improve maternal–child health outcomes. In addition, focused efforts are required to reduce the rate of unnecessary CS through adherence to evidence-based guidelines and promoting safe vaginal births when appropriate.
Keywords
COVID 19
Perinatal Mortality
Uterine Rupture
INTRODUCTION
Background of the Study
Uterine rupture is a rare but grave obstetric complication and involves the complete separation of all three uterine layers: The endometrium, myometrium, and perimetrium. It is associated with significant maternal and neonatal morbidity and mortality. Globally, the incidence of uterine rupture ranges from 0.03% to 0.1% in developed countries, but it can be as high as 0.5–1.0% in low-resource settings.[1] In India, the incidence has been reported to vary between 0.1% and 0.7%, and it remains a notable contributor to maternal deaths, accounting for approximately 5–10% of maternal mortality in some studies.[2] The incidence of this major obstetric hazard is on the rise, largely due to the increasing rate of cesarean section (CS) deliveries. The etiology differs across settings: in high-income countries, uterine rupture is primarily associated with a prior CS, particularly during a trial of labor after cesarean (TOLAC). In contrast, in low-resource settings, risk factors include obstructed labor, grand multiparity, injudicious use of uterotonic agents, instrumental delivery, and limited access to emergency obstetric services, especially in rural areas.[3-5] Cesarean section rates are rising globally. From the current average of 21.1%, it is expected to reach 28.5% by 2030, raising concerns over complications, including uterine rupture. Women with prior classical or vertical uterine incisions face a significantly higher risk of rupture compared to those with previous low transverse incisions.[6,7].
Objectives of the Study
The objective of the study is to estimate the prevalence of uterine rupture among women attending a tertiary care center and assess its contribution to maternal morbidity and mortality in the context of rising CS rates.
Specific Aims and Hypothesis
The present study aimed to explore the contributing factors, their management, and maternal and fetal outcomes of patients with ruptured uteri.
METHODS
This is a facility-based cross-sectional study carried out in the department of obstetrics and gynecology at a tertiary care center in Eastern Uttar Pradesh, India. This center serves as a major referral hospital for a large geographical area, catering to both urban and rural populations with varying socioeconomic backgrounds. The study was conducted over one year, from October 2019 to September 2020. Notably, the COVID-19 pandemic emerged during this study. Therefore, the incidence of uterine rupture during the COVID-19 period, specifically from March 2020 to September 2020 (7 months), was calculated separately to assess any potential impact of the pandemic on the incidence or management of uterine rupture. All pregnant women admitted for delivery were tested for COVID-19 as per the Indian Council of Medical Research guidelines that existed at the time. Testing was conducted using reverse transcription polymerase chain reaction and nasal swab samples, even in asymptomatic individuals. Patients who tested positive for COVID-19 were managed as per established guidelines in a separate COVID-19-designated 200-bedded level 3 hospital, under the joint care of obstetricians and physicians. For neonates born to COVID-19-positive mothers, nasal swabs for COVID-19 testing were collected 24 hours after birth, following institutional protocols, and the results were recorded. The present study aimed to determine the clinical and demographic profile of patients with ruptured uteri during the intranatal period and evaluate the contributing factors, their management, and maternal and fetal outcomes.
Reporting guideline: This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines as recommended by the EQUATOR network.[8]
Study Variables
All clinically diagnosed and laparotomy-confirmed cases of uterine rupture admitted to the obstetrics and gynecology department of the hospital during the study were included in this study. Baseline sociodemographic factors were recorded, including age, socioeconomic status, educational level, whether the patient lived in a rural or urban area, whether the case was booked or not, scarred or unscarred uterus, number of previous CS, the outcome of the previous pregnancy, details about the current pregnancy and labor, as well as the outcomes for both the mother and the baby.
Statistical Analysis
The collected data underwent statistical analysis to derive meaningful insights. Descriptive statistics, including measures such as means, standard deviations, frequencies, and percentages, were computed to provide a concise summary of the data.
The occurrence of uterine rupture cases during the COVID-19 and non-COVID-19 periods was compared using a Z-test for proportions, with a significance level set at 0.05.
We calculated the incidence of rupture from the total number of hospital deliveries during the study.
RESULTS
Sociodemographic Characteristics
Table 1 shows that the maximum number of rupture uterus cases (70.97%) were in the age group of 20–30 years with a mean of 25 years; majority were from rural areas and lower socioeconomic status. 80.64% of women were multigravida (between gravida 2 and 4), and a higher percentage of women (38.71%) were illiterate (defined as inability to write or read her own name).
| Variable | Number (n=31) | Percentage |
|---|---|---|
| Age-years | ||
| 20–30 | 22 | 70.97 |
| 31–40 | 09 | 29.03 |
| Background | ||
| Rural | 25 | 80.64 |
| Urban | 06 | 19.35 |
| Gravidity (G) | ||
| G1 | 01 | 3.23 |
| G 2–4 | 25 | 80.64 |
| G 5–7 | 05 | 16.13 |
| Educational status | ||
| Illiterate | 12 | 38.71 |
| High school | 18 | 58.06 |
| Graduate | 01 | 3.23 |
| Booking status | ||
| Booked | 08 | 25.81 |
| Unbooked | 23 | 74.19 |
| Previous uterine scar | ||
| Present | 20 | 64.52 |
| Absent | 11 | 35.50 |
| H/O Dilatation and evacuation | 02 | 6.45 |
| Previous CS | 16 | 51.61 |
| 01 | 14 | 45.16 |
| 02 | 02 | 6.45 |
| VD+CS | 04 | 12.90 |
| Labour Onset | ||
| Spontaneous | 28 | 90.32 |
| Induced | 03 | 9.68 |
| Augmentation | 08 | 25.81 |
| Duration of labour | ||
| <10 h | 05 | 16.13 |
| 10–20 h | 18 | 58.06 |
| 21–30 h | 06 | 19.35 |
| >30 h | 01 | 3.23 |
| Not known | 01 | 3.23 |
| Place of trial of labour | ||
| Home | 14 | 45.16 |
| Health facility | 17 | 54.84 |
| Obstructed labour | 05 | 16.13 |
CS: Cesarean section, VD: Vaginal delivery
The pregnancy and labor characteristics of women with ruptured uteruses showed [Table 1] that 74.19% of cases were unbooked, and 64.52% had previous uterine surgeries, mostly CS. Of these, 45.16% had a previous one cesarean delivery. 6.45% of cases underwent dilatation and evacuation procedures. Only 9.68% of cases required induced labor, while 90.32% of women presented with spontaneous onset of labor. 25.81% received augmentation of labor by oxytocin. Maximum rupture of the uterus occurred in 10–20 hours of labor (58.06%), with a higher incidence at health facilities as compared to at home trials of labor (54.84% vs. 45.16%). There were 16.13% cases due to obstructed labor.
Main Variable (Maternal and Neonatal Outcome)
Maternal outcome of uterine rupture cases, as shown in Table 2, 93.55% of women were managed well and discharged in stable condition, 51.61% required intensive care unit (ICU) admission, one patient out of 31 required re-exploration due to post-operative hemoperitoneum, one experienced abdominal wound dehiscence, and one had developed ureterovaginal fistula. Two cases succumbed due to sepsis and shock (6.45%).
| Parameters | Number (n=31) | Percentage |
|---|---|---|
| Improved and discharge in stable condition | 29 | 93.55 |
| Re-exploration for hemoperitoneum | 01 | 3.23 |
| ICU admission | 16 | 51.61 |
| Wound dehiscence | 01 | 3.23 |
| Ureterovaginal fistula | 01 | 3.23 |
| Maternal mortality | 02 | 6.45 |
| Intrauterine death at admission | 26 | 83.87 |
| Live fetus on admission | 05 | 16.13 |
| Died within 2–3 days of birth. (APGAR score: at 1 and 5 min 2, 4 3, 4 3, 4 2, 3) |
04 | 12.90 |
| Neonatal Survival (APGAR score at 1 and 5 min: 4, 6) |
01 | 3.23 |
APGAR: Appearance, Pulse, Grimace, Activity and Respiration
Uterine rupture cases had poor neonatal outcomes, as 26 (83.87%) cases presented with absent fetal heart at admission, and only five (16.13%) fetuses were alive on admission, out of which only one neonate (3.23%) survived with Appearance, Pulse, Grimace, Activity and Respiration (APGAR) scores of 4 and 6 at 1 and 5 min of birth; the rest four had lower APGAR scores and expired within 2–3 days of birth [Table 2].
Other Variable(s) (Covariates)
Findings during surgery showed that 41.94% of cases had a lower segment scar rupture, 22.58% had an extension of the previous lower segment scar, and 19.35% had a rupture of the lateral wall of the uterus [Table 3]. Injury to the adjacent structures affected the urinary bladder most (12.90%), followed by the broad ligament, cervix, and vagina. 45.16% of cases had 1,000–1,500 mL total blood loss; only 6.45% had >1500 mL blood loss, managed by blood and blood product transfusion accordingly. Average blood loss was 1,016 mL. In 54.84% of cases, the fetus was found to be present within the peritoneal cavity, while in 45.16% of cases, the fetus was detected intrauterine. The finding of adherent placenta was noted in 9.68% of cases.
| Parameters | Number (n=31) | Percentage |
|---|---|---|
| Site and extent of rupture | ||
| Scar site rupture | 13 | 41.94 |
| Extension of previous lower segment scar | 07 | 22.58 |
| Anterior wall | 03 | 9.68 |
| Posterior wall | 02 | 6.45 |
| Lateral wall | 06 | 19.35 |
| Injury to adjacent structures | ||
| Urinary bladder | 04 | 12.90 |
| Cervix | 02 | 6.45 |
| Vagina | 01 | 3.23 |
| Broad ligament | 03 | 9.68 |
| Total blood loss | ||
| 500 mL | 05 | 16.13 |
| 500–1,000 mL | 10 | 32.26 |
| 1,000–1,500 mL | 14 | 45.16 |
| >1,500 mL | 02 | 6.45 |
| Fetus position | ||
| In-utero | 14 | 45.16 |
| In the peritoneal cavity | 17 | 54.84 |
| Adherent placenta | 03 | 9.68 |
| Rupture repair with tubectomy | 20 | 64.52 |
| Rupture repair with stepwise devascularization | 05 | 16.13 |
| Rupture repair with compression sutures | 01 | 3.23 |
| Total hysterectomy | 05 | 16.13 |
Uterine rupture cases were managed by repair of the rupture site in 64.52% of cases; 16.13% required devascularization, 3.23% were managed with compression sutures along with repair of the rupture site, and 16.13% of cases required total hysterectomy [Table 3].
DISCUSSION
This study found a notably high incidence of uterine rupture, 8.7/1,000 deliveries, which is substantially greater than that reported in high-income countries (0.03–0.1%) but comparable to figures from other Indian tertiary centers, where the incidence ranges between 0.1% and 0.7%.[1,2] The observed increase in incidence during the COVID-19 pandemic (from 7.6 to 9.85/1,000 deliveries) is clinically relevant, though statistically not significant (Z = 0.72) [Table 4]. Similar trends have been reported elsewhere, likely due to delays in accessing care and disruption of health services during the pandemic.[9]
| Period | Total number of deliveries | Number of uterine rupture cases | Incidence | Z-score |
|---|---|---|---|---|
| Pre-COVID-19 (October 2019–February 2020) | 1,827 | 14 | 7.6/1,000 | 0.72 |
| During COVID-19 (March 2020–September 2020) | 1,725 | 17 | 9.85/1,000 | |
| Total | 3,552 | 31 | 8.72/1,000 |
Most women in this cohort were aged 20–30 years, from rural areas, and of lower socioeconomic status. A significant proportion (38.71%) was illiterate [Table 1]. These findings mirror previous Indian studies where poverty, lack of education, and rural residence emerged as significant contributors to uterine rupture.[3,5] Notably, 74.19% of women were unbooked, reflecting inadequate antenatal care and late presentation, which is a known risk factor for poor maternal outcomes. 64.52% had had scarred uterus due to CS [Table 1], affirming its role as the most significant risk factor for uterine rupture globally.[10] Nearly half of these women labored at home, often without supervision, a particularly hazardous scenario for those with a scarred uterus. This aligns with findings by Landon et al., who emphasized the risks associated with unsupervised TOLAC, particularly in women with a prior classical or midline incision.[11]
Spontaneous labor onset occurred in the majority (90.32%), while 25.81% underwent labor augmentation. Prolonged labor (10–20 hours) was common, and obstructed labor was identified in 16.13% of cases [Table 1]. These findings are consistent with other studies identifying unsupervised or mismanaged labor as a major contributor to uterine rupture, especially in multigravida women.[12]
Lower-segment scar rupture was the most common anatomical site (41.94%), and more than half of the fetuses were found to be present within the peritoneal cavity. Injury to adjacent structures, particularly the urinary bladder, was seen in 12.90%, similar to complication rates reported in other Indian case series.[13] The average blood loss was substantial (1,016 mL), though transfusion management was effectively instituted [Table 3].
Uterine rupture management
Uterine rupture cases were managed by repair of the rupture site, and the uterus was saved in most (26/31, 83.87%) of cases. Only five (16.13%) cases required total hysterectomy [Table 3]. This reflects timely surgical intervention and the evolving preference toward uterine preservation where feasible, as also supported by other Indian studies.[14]
Maternal survival was achieved in 93.55% of cases, with 51.61% requiring ICU admission. However, two women succumbed to sepsis and shock (6.45%) [Table 2]. This falls within the range reported in similar Indian studies (4–8%).[13,14] Post-operative complications such as hemoperitoneum, wound dehiscence, and ureterovaginal fistula underscore the complexity of managing such cases.
Neonatal outcomes were dismal. Fetal heart sounds were absent on admission in 83.87% of cases, and only one neonate (3.23%) survived [Table 2]. This unfavorable outcome is echoed in studies where delayed presentation and lack of intrapartum monitoring were associated with extremely high perinatal mortality in uterine rupture.[15]
Limitations of the Study
A key limitation of this study was the unavailability of detailed data on the dosage, duration, and mode of administration of uterotonic agents such as oxytocin and prostaglandins, which limited our ability to analyze their role as potential risk factors for uterine rupture. In addition, as a single-center study, the generalizability of findings is constrained. Future large-scale, multicenter prospective studies are warranted to better elucidate the multifactorial etiology, identify modifiable risk factors, and guide standardized protocols for the prevention and management of uterine rupture.
CONCLUSION AND GLOBAL HEALTH IMPLICATIONS
This study highlights a significantly high prevalence of uterine rupture among pregnant women in rural Eastern Uttar Pradesh, predominantly associated with preventable factors such as unbooked status, previous cesarean sections, prolonged or mismanaged labor, and deliveries conducted at home or in inadequately equipped peripheral centers. To effectively reduce the burden of this life-threatening complication, a multifaceted strategy is needed. Priority should be given to strengthen antenatal risk assessment and ensure that women with a scarred uterus are referred early to tertiary care centers. Implementing tele-obstetric referral systems can bridge the communication gap between peripheral and tertiary centers, allowing coordinated transfer of high-risk pregnancies. Targeted training of labor room staff at all levels, particularly regarding the rational and safe use of uterotonics, is crucial. Standardized protocols on appropriate dosing and indications for induction and augmentation should be emphasized to prevent misuse that can lead to uterine rupture.
In addition, focused efforts are required to reduce the rate of unnecessary CS through adherence to evidence-based guidelines and promoting safe vaginal births when appropriate.
Strengthening referral linkages, enhancing awareness through community engagement, and enforcing adherence to clinical protocols can collectively reduce maternal and perinatal mortality due to uterine rupture in low-resource settings.
Key Messages
(1) Uterine rupture is a life-threatening but preventable complication, more common in rural and low-resource areas. (2) Main risk factors are previous cesarean, unbooked pregnancy, prolonged labor, injudicious use of uterotonic, and unsupervised trial of labor after cesarean. (3) Improving antenatal care, training of healthcare personnel, instituting and strengthening the tele obstetric referral system, and avoiding unnecessary cesareans can help prevent uterine rupture.
Acknowledgments:
None.
COMPLIANCE WITH ETHICAL STANDARDS
Conflicts of Interest: The authors declare no competing interests. Financial Disclosure: Nothing to declare. Funding/Support: There was no funding for this study. Ethics Approval: The research/study was approved by the Institutional Review Board at College Research Council, number 08/CRC/2019, dated October 24, 2019. Declaration of Patient Consent: The authors certify that they have obtained all appropriate patient consent. Use of Artificial Intelligence (AI)-Assisted Technology for Manuscript Preparation: The authors confirm that they have used artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript or image creations. Disclaimer: None.
References
- Clinical analysis of complete uterine rupture during pregnancy. BMC Pregnancy Childbirth. 2024;24:255.
- [CrossRef] [PubMed] [Google Scholar]
- Uterine rupture-a 10 years review in tertiary hospital. Ind J Obstet Gynecol Res. 2018;5(3):409-12.
- [CrossRef] [Google Scholar]
- Lived experiences of women who developed uterine rupture following severe obstructed labor in Mulago hospital, Uganda. Reprod Health. 2014;11:31.
- [CrossRef] [PubMed] [Google Scholar]
- Analysis of uterine rupture at university teaching hospital Pakistan. Pak J Med Sci. 2015;31(4):920-4.
- [Google Scholar]
- Risk factors and perinatal outcome of uterine rupture in a low-resource setting. Niger Med J. 2013;54(6):415-9.
- [CrossRef] [PubMed] [Google Scholar]
- Trends and projections of caesarean section rates: Global and regional estimates. BMJ Glob Health. 2021;6(6):e005671.
- [CrossRef] [PubMed] [Google Scholar]
- 184: Vaginal birth after caesarean delivery. Obstet Gynecol. 2017;130(5):e217-33.
- [CrossRef] [Google Scholar]
- The STROBE guidelines. Saudi J Anaesth. 2019;13(Suppl 1):S31-4.
- [CrossRef] [PubMed] [Google Scholar]
- COVID-19 outbreak and decreased hospitalisation of pregnant women in labour. J Family Med Prim Care. 2021;10(1):100-4.
- [Google Scholar]
- Vaginal birth after cesarean: New insights. Evid Rep Technol Assess (Full Rep). 2010;191:1-397.
- [Google Scholar]
- Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med. 2004;351(25):2581-9.
- [CrossRef] [PubMed] [Google Scholar]
- Unscarred uterine rupture: A retrospective analysis. Int J Reprod Contracept Obstet Gynecol. 2022;11(4):1269-71.
- [CrossRef] [Google Scholar]
- Rupture uterus in a tertiary care centre. Int J Reprod Contracept Obstet Gynecol. 2022;12(1):201-5.
- [CrossRef] [Google Scholar]
- Uterine rupture: Still a harsh reality! J Obstet Gynaecol India. 2015;65:158-61.
- [CrossRef] [PubMed] [Google Scholar]
- Maternal and fetal outcomes of uterine rupture and factors associated with maternal death secondary to uterine rupture. BMC Pregnancy Childbirth. 2017;17(1):117.
- [CrossRef] [PubMed] [Google Scholar]