A 28-year-old gravida 3, para 2 client at 38 weeks gestation is admitted to the labor and delivery unit with strong, frequent contractions. She has a history of two previous cesarean deliveries. During active labor, the client suddenly screams in severe pain, and the fetal heart rate drops to 80 bpm with late decelerations. The client's vital signs show: BP 90/50 mmHg, HR 120 bpm, and she appears pale and diaphoretic. What is the nurse's immediate priority action?
1Administer oxygen via face mask at 10 L/min
2Increase the IV fluid rate and notify the physician
3Stop oxytocin infusion immediately and prepare for emergency cesarean delivery✓ 정답
4Reposition the client to left lateral position and continue monitoring
해설
In suspected uterine rupture, the immediate priority is to stop oxytocin infusion and prepare for emergency cesarean delivery to prevent maternal hemorrhage and fetal hypoxia. Other options like oxygen administration or repositioning are supportive but secondary to urgent surgical intervention.
Clinical Presentation Analysis
This client presents with a classic triad of uterine rupture: sudden, severe abdominal pain during active labor, a precipitous drop in fetal heart rate (80 bpm with late decelerations), and maternal hemodynamic instability (BP 90/50 mmHg, HR 120 bpm, pallor, diaphoresis). The history of two prior cesarean deliveries is the most significant risk factor, as a scarred uterus is present in the vast majority of rupture cases [2].
Pathophysiology and Risk Factors
A complete uterine rupture involves a full-thickness disruption of the myometrium and serosa, confirmed intraoperatively [2]. The risk is directly related to the type of uterine scar; a classical (vertical) cesarean incision carries the highest risk, though a low transverse scar, common in prior deliveries, also elevates risk during a trial of labor . The strong, frequent contractions described suggest possible tachysystole from oxytocin administration, which increases intrauterine pressure and wall tension, predisposing the scarred segment to dehiscence. When rupture occurs, the uterine contents can be extruded into the peritoneal cavity, causing catastrophic hemorrhage, placental abruption, and acute fetal hypoxia, reflected in the profound bradycardia .
Prioritization of Interventions
The immediate priority is to stop any agent that is increasing uterine wall stress. If oxytocin is infusing, discontinuing it removes the stimulus for further contractions, which could extend the rupture and worsen hemorrhage . Simultaneously, preparation for emergency cesarean delivery must begin, as definitive surgical repair and fetal rescue are the only life-saving measures. Maternal stabilization and fetal resuscitation are concurrent, not primary, actions in this scenario because the underlying cause is mechanical disruption that requires surgical correction.
Analysis of Incorrect Options
- Option 1 (Administer oxygen): Oxygen supplementation is a supportive measure for fetal resuscitation but does not address the catastrophic loss of uterine integrity and placental perfusion. It is secondary to stopping the oxytocin and preparing for surgery.
- Option 2 (Increase IV fluids and notify physician): Fluid resuscitation is critical for managing hemorrhagic shock, and physician notification is essential. However, this option fails to include the most immediate nursing action: discontinuing the uterotonic agent. Stopping oxytocin takes seconds and directly impacts the pathophysiology.
- Option 4 (Reposition to left lateral): Lateral positioning relieves aortocaval compression and may transiently improve maternal cardiac output and fetal oxygenation, but it is ineffective in the face of active uterine rupture and exsanguination. Continuous monitoring without immediate intervention delays definitive care.
Clinical Decision-Making Framework
The nurse's immediate priority action follows the "find and fix the cause" principle. The client's history and sudden deterioration point to uterine rupture as the precipitating event. The most direct and rapid intervention the nurse can perform to halt the progression of this emergency is cessation of oxytocin, which directly reduces the force driving the rupture. This action is the critical first step in the coordinated rapid response that includes fluid resuscitation, preparation for emergency surgery, and neonatal resuscitation team activation . The incidence of complete uterine rupture is low (0.044% in one cohort), but when it occurs in a scarred uterus, the time from recognition to surgical intervention is the primary determinant of maternal and neonatal outcomes [2].
References (research sources)
[2]
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
Uterine Rupture: Emergency Nursing Protocol
This clinical guide outlines the immediate recognition and management of uterine rupture during a trial of labor after cesarean (TOLAC). Rapid intervention is critical to prevent maternal exsanguination and fetal demise.
1. Clinical Recognition
Classic Triad: Sudden, severe, tearing abdominal pain; cessation of contractions; and profound fetal bradycardia (often < 80 bpm) with late or prolonged decelerations.
Maternal Signs: Hemodynamic instability (hypotension, tachycardia, pallor, diaphoresis) indicating significant intra-abdominal hemorrhage. Loss of uterine contour and easily palpable fetal parts may be present.
Risk Factors: Prior cesarean delivery (especially classical incision), grand multiparity, injudicious oxytocin use leading to tachysystole, and uterine overdistension.
2. Immediate Priority Actions
Stop Uterotonic Agents: Immediately discontinue oxytocin infusion to reduce uterine wall tension and prevent extension of the rupture.
Activate Emergency Response: Call for immediate obstetric, anesthesia, and neonatal resuscitation team assistance. Declare a "Code C" or emergency cesarean.
Prepare for Surgery: Initiate massive transfusion protocol; insert a second large-bore IV line; administer oxygen via non-rebreather mask; and prepare the abdomen for emergency laparotomy.
Maternal Resuscitation: Position the patient supine with a left lateral tilt to maximize cardiac output while preparing for rapid transport to the operating room. Aggressive fluid resuscitation with crystalloids and blood products is essential.
3. Perioperative Nursing Considerations
Informed Consent: While the physician obtains surgical consent, the nurse explains the emergency need for surgery, including the possibility of hysterectomy.
Neonatal Team: Ensure the neonatal resuscitation team is present with equipment for a severely depressed infant (meconium aspirator, endotracheal tube, epinephrine).
Documentation: Record the time of symptom onset, time of oxytocin discontinuation, vital signs, and the decision-to-incision interval.
4. Postoperative Monitoring
Hemorrhage Vigilance: Monitor for ongoing bleeding, signs of disseminated intravascular coagulation (DIC), and uterine atony post-repair.
Psychosocial Support: Provide emotional support regarding the emergency birth, potential loss of fertility, and neonatal outcomes.
Uterine Rupture — A full-thickness disruption of the uterine wall, most commonly occurring at the site of a previous cesarean scar, leading to maternal hemorrhage and fetal distress.
Tachysystole — Excessively frequent uterine contractions, often defined as more than 5 contractions in 10 minutes, which can be caused by oxytocin and increase the risk of uterine rupture.
Late Decelerations — A fetal heart rate pattern indicating uteroplacental insufficiency, where the deceleration begins after the peak of a contraction and returns to baseline after the contraction ends.
Trial of Labor After Cesarean (TOLAC) — A planned attempt at vaginal delivery in a patient with a prior cesarean birth, which carries a risk of uterine rupture, especially with labor augmentation.
Classical Cesarean Incision — A vertical incision into the upper uterine segment, which has a significantly higher risk of rupture in subsequent pregnancies compared to a low transverse incision.