Management of ruptured uterus depends on the cause, the presentation, the need to preserve the uterus, and the part of the uterus involved in the rupture.

Resuscitation is a very important first aid and must be initiated as soon as rupture is suspected. Effective resuscitation to keep the blood pressure above 90 mm of Hg systolic is a very important step to prevent postoperative complications. Initial resuscitation with crystalloids (maximum up to 1.5 l in 1 h) and blood is necessary. Overuse of crystalloids without blood would result in dilution and consumption coagulopathy, compounding the bleeding. However, resuscitation and preparation for definitive surgical management should be carried out parallel. Delay beyond 1 h from diagnosis is likely to result in the life-threatening sequel and even death. With abnormal foetal heart rate pattern in a woman with a previous caesarean scar in labour, the time delay beyond 15 min to a half hour would result in perinatal mortality. It is important to ensure round-the-clock availability of blood, anaesthetist and operation theatre facility, and skilled obstetricians before planning the delivery of women with higher risk of rupture like women with a previously scarred uterus.

Most of the ruptures associated with previous lower segment caesarean sections have a subacute maternal presentation with the rupture restricted to the lower segment. Most of these are amenable to repair. Repair should always be attempted and is most likely to be successful when the rupture is restricted to the lower segment and is a fresh rupture. In a study period of 10 years, Alemayehu and co-authors [1] observed that 98 % of cases with rupture were successfully repaired by the doctors even though they were nonspecialized doctors. The authors further observed that the maternal mortality increases sevenfold if there is more than 1 h delay in definitive treatment.

One needs to keep in mind the recurrence of rupture in subsequent pregnancies. Eshkoli and co-authors [3] observed a recurrent risk of rupture to be 15 %. Fox et al. [4] studied the outcome of pregnancies with previous ruptures and observed that those who had a dehiscence of scar in the previous pregnancy or labour had a higher risk of repeat dehiscence at 7.5 %. However, they observed that management of these patients with standard protocol by repeat elective caesarean sections would not increase the maternal or perinatal morbidity or mortality.

In situations where there is associated colporrhexis or extension of the rupture to the lateral wall, a hysterectomy might become necessary. In a population-based study spanning over 23 years, Charach and Sheiner [2] recorded 164 ruptures and observed that the woman is likely to have a hysterectomy if she is subjected to relaparotomy, if there is an extension of a tear to cervix or fornix, if there is continued bleeding requiring multiple transfusions, and if she is a multiparous woman.

Ruptures involving the upper segment invariably merit a hysterectomy. Similarly, tears of the lateral wall involving the uterine artery or bleeding into the broad ligament are also likely to require a hysterectomy. Repair can be attempted if the tear is linear, but future pregnancies should be avoided as the risk of subsequent rupture is very high, and so tubal ligation should be performed along with repair after counselling. If the rupture is due to an invasive mole or the margins are ragged, and there is a loss of tissue, hysterectomy becomes necessary.

Caesarean hysterectomy is a skilled procedure. The surgery needs to be very fast. Preoperative urinary catheterization is must to not only rule out bladder rupture but also aid in the diagnosis of urinary tract injuries during the surgery as the chances of urinary tract injuries are high during caesarean hysterectomy, and of course, urine output during the surgery is an important measure of effective maintenance of circulation. In women suspected with a rupture, the abdomen should be preferably opened by vertical midline sub-umbilical incision. After the foetus and placenta are extracted from the abdominal cavity, the uterus should be delivered out and inspected for the site and size of rupture, the condition of the edges, the involvement of the uterine arteries, and the bleeding from the edges, as also for broad ligament bleeding in situations involving the lateral wall and the uterine arteries.