A nurse is caring for a client who is experiencing a complete uterine rupture during labor. What is the most immediate nursing intervention?
A 28-year-old gravida 3, para 2 client at 38 weeks gestation is in active labor when she suddenly experiences severe abdominal pain and reports feeling like "something tore inside." The fetal heart rate drops to 60 bpm, and the client becomes hypotensive with a blood pressure of 80/50 mmHg. The nurse suspects complete uterine rupture.
1Immediately prepare the client for emergency cesarean section and notify the surgical team✓ 정답
2Administer oxygen via face mask and increase intravenous fluid rate
3Position the client in Trendelenburg and monitor vital signs closely
4Perform Leopold's maneuvers to assess fetal position and presentation
해설
Complete uterine rupture is a life-threatening obstetric emergency requiring immediate surgical intervention to save both maternal and fetal lives. Other options are supportive but secondary to emergency cesarean section.
Understanding Complete Uterine Rupture
A complete uterine rupture is defined as a full-thickness disruption of the myometrium and serosal layer, confirmed during surgery [1]. This catastrophic obstetric emergency creates a direct communication between the uterine cavity and the peritoneal cavity, leading to fetal extrusion, massive maternal hemorrhage, and acute fetal distress. The incidence is rare, occurring in approximately 0.044% of deliveries, but the consequences are devastating without immediate intervention [1].
Pathophysiology and Clinical Presentation
The client's report of a tearing sensation, sudden severe abdominal pain, profound fetal bradycardia (60 bpm), and maternal hypotension (80/50 mmHg) represent the classic triad of uterine rupture. When the uterine wall tears completely, the fetus is expelled from the protective intrauterine environment into the abdominal cavity. This causes instantaneous loss of uterine wall tension, placental separation or compression, and umbilical cord compromise, directly explaining the rapid fetal heart rate decline. Simultaneously, the torn uterine vessels bleed freely into the peritoneal cavity, causing hypovolemic shock in the mother. The risk is highest in clients with a scarred uterus, which accounts for 86.4% of cases, typically from prior cesarean sections or uterine surgeries [1][3].
Why Immediate Surgical Preparation Is the Priority
In complete uterine rupture, the fetal and maternal conditions deteriorate in minutes, not hours. The only definitive treatment is immediate laparotomy and emergency cesarean section to deliver the fetus, control hemorrhage, and repair or remove the damaged uterus [3]. Every minute of delay increases the risk of adverse neonatal outcomes, including hypoxic-ischemic encephalopathy and death, and pushes the mother closer to irreversible hemorrhagic shock [1]. Preparing the client for surgery involves notifying the surgical and anesthesia teams, ensuring blood products are available, and physically moving the client to the operating room without delay. This action directly addresses the underlying cause of both fetal and maternal compromise.
Analysis of Incorrect Options
- Option 2 (Administer oxygen and increase IV fluids): These are supportive measures that temporarily augment maternal oxygenation and intravascular volume. However, they do not stop the ongoing intra-abdominal hemorrhage or relieve the fetal asphyxia caused by placental separation. They are performed concurrently with, but are secondary to, preparing for definitive surgical intervention.
- Option 3 (Position in Trendelenburg and monitor vitals): Trendelenburg positioning may transiently improve venous return in hypovolemic shock, but it does not address the surgical emergency. Continuous monitoring is important but passive; the priority is active preparation for the life-saving laparotomy that will actually control the bleeding source.
- Option 4 (Perform Leopold's maneuvers): Leopold's maneuvers are used to assess fetal lie, presentation, and position in a stable laboring client. In a suspected complete rupture, the fetal parts may be palpable abdominally outside the uterus, but performing this assessment wastes critical time and delays the emergency surgical response that is already clinically indicated by the classic presentation and fetal bradycardia .
References (research sources)
[1]
Factors Associated with Adverse Neonatal Outcomes in Complete Rupture of the Pregnant Uterus: A Single-Center Cohort Study.Research articleGil B, Shim S, Jang Y, Shin JS, Lee N, Kim MK, Jung YW, Seong SJ, Kim ML. (2026) · DOI: 10.3390/jpm16060327
[3]
Second-Trimester Uterine Rupture in a Multiple-Scar Uterus Complicated by Placenta Accreta Spectrum: A Case Report and Literature Review.Case reportChatziioannou SS, Papasideri V, Palaiologos P. (2026) · DOI: 10.7759/cureus.108892
Clinical Management of Complete Uterine Rupture
Complete uterine rupture is a catastrophic obstetric emergency requiring immediate, coordinated surgical intervention. The nursing priority is to recognize the classic signs and activate the emergency response system without delay.
Immediate Nursing Actions
Activate the Emergency Response: Call for immediate assistance from the obstetric, anesthesia, and neonatal resuscitation teams. Declare a code or obstetric emergency per facility protocol.
Prepare for Emergency Cesarean Section: The definitive treatment is immediate laparotomy and delivery of the fetus. The nurse should prepare the surgical site, ensure intravenous access with large-bore catheters, and anticipate massive transfusion protocol activation.
Maternal Resuscitation: While preparing for surgery, administer high-flow oxygen via a non-rebreather mask and rapidly infuse isotonic crystalloids or blood products to combat hypovolemic shock. Continuous maternal vital sign monitoring is essential.
Intraoperative and Postoperative Priorities
Fetal Resuscitation: The neonatal team must be present to provide immediate advanced life support, as the neonate is likely to be severely depressed due to hypoxia and placental compromise.
Hemorrhage Control: Surgical options include repair of the uterine defect or hysterectomy if the rupture is extensive or bleeding is uncontrollable. The nurse must be prepared to assist with blood product administration and fluid warming.
Postoperative Monitoring: Closely monitor for signs of disseminated intravascular coagulation (DIC), acute kidney injury, and Sheehan's syndrome (postpartum pituitary necrosis) due to the profound hypotensive episode.
Risk Factors and Prevention
Prior Uterine Surgery: The most significant risk factor is a scarred uterus from a previous cesarean section (especially classical incision) or myomectomy. A trial of labor after cesarean (TOLAC) requires strict monitoring.
Labor Augmentation: Excessive use of oxytocin or prostaglandins for induction or augmentation can increase the risk, particularly in a scarred uterus.
Trauma and Grand Multiparity: External trauma or a thin uterine wall from multiple prior deliveries are additional risk factors.
Key Nursing Insight: Any laboring client with a history of uterine surgery who reports sudden, severe abdominal pain and a tearing sensation must be evaluated immediately for rupture. Fetal bradycardia in this context is a late sign indicating fetal extrusion and profound distress. Do not delay definitive surgical management for diagnostic tests or supportive measures alone.
Complete Uterine Rupture — A full-thickness disruption of the myometrium and serosal layer, creating a communication between the uterine and peritoneal cavities, leading to fetal extrusion and massive hemorrhage.
Classic Triad of Uterine Rupture — Sudden severe abdominal pain, a tearing sensation, and profound fetal bradycardia, often accompanied by maternal hypotension.
Emergency Cesarean Section — An immediate surgical delivery performed to rapidly rescue the fetus and control maternal hemorrhage when vaginal delivery is not safe or possible.