# A nurse is caring for a client at 41 weeks gestation who is undergoing induction of labor with oxytocin. The client suddenly reports severe abdominal pain and states 'something tore inside me.' The fetal heart rate drops from 140 bpm to 80 bpm, and the client becomes hypotensive with a thready pulse. What is the nurse's immediate priority action?

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> subject: Maternal Newborn Health

## 문제

A nurse is caring for a client at 41 weeks gestation who is undergoing induction of labor with oxytocin. The client suddenly reports severe abdominal pain and states 'something tore inside me.' The fetal heart rate drops from 140 bpm to 80 bpm, and the client becomes hypotensive with a thready pulse. What is the nurse's immediate priority action?

Emergency management of suspected uterine rupture during labor

## 보기

1. Administer oxygen via face mask at 10 L/min
2. Insert two large-bore IV catheters and begin fluid resuscitation
3. Prepare the client for immediate cesarean delivery **✔ 정답**
4. Stop all uterine stimulants and place client in left lateral position

**정답: 3**

## 해설

The immediate priority for suspected uterine rupture is to prepare for emergency cesarean delivery, as it is a surgical emergency. Stopping uterine stimulants and positioning are supportive but secondary actions.

## 심화 해설

Clinical Priority Analysis

The scenario describes a catastrophic obstetric emergency: a sudden onset of severe abdominal pain with a tearing sensation, acute fetal bradycardia (drop from 140 bpm to 80 bpm), and maternal hypotension with a thready pulse. This clinical triad is the classic presentation of a uterine rupture.

Pathophysiology and Rationale for Immediate Action

In a complete uterine rupture, the integrity of the uterine wall is lost, leading to partial or complete expulsion of the fetus and placenta into the maternal abdominal cavity. This causes catastrophic maternal hemorrhage and an abrupt cessation of placental perfusion. The fetal heart rate drops precipitously due to acute hypoxia, and the mother becomes hypotensive from massive blood loss. The tearing sensation reported by the client is caused by the mechanical separation of the uterine muscle fibers.

In this context, the only definitive treatment that can save both the mother and the fetus is immediate surgical intervention. The case report by Sisay et al. (2024) underscores that even in patients without typical risk factors—such as the primigravid mother in their report—uterine rupture can occur, and the outcome hinges on "prompt action." That prompt action, once the diagnosis is suspected, is an emergency laparotomy to deliver the fetus, control hemorrhage, and repair the uterus [1]. Any delay in moving to the operating room directly increases the risk of fetal death from anoxia and maternal death from exsanguination.

Why Other Options Are Not the Immediate Priority

While the other listed interventions are critical components of the resuscitation bundle, they are preparatory or supportive measures that must occur concurrently with, but not instead of, the definitive treatment.

- Stopping uterine stimulants and repositioning (Option 4): This is a crucial first step to reduce uterine tension and improve maternal perfusion, but it does not address the ongoing fetal anoxia or the internal hemorrhage. It is a preparatory action, not the definitive solution.

- Administering oxygen and inserting IV lines (Options 1 and 2): These are essential for maternal and fetal oxygenation and for volume resuscitation to manage hemorrhagic shock. However, these are supportive measures to stabilize the client en route to the operating room. The definitive resolution of the crisis—stopping the hemorrhage and delivering the compromised fetus—can only be achieved through immediate cesarean delivery.

The nurse's immediate priority action is to activate the chain of events that leads to the operating room, which means preparing the client for an immediate cesarean delivery. All other interventions are performed simultaneously by the team but are secondary to the singular goal of rapid surgical delivery.References (research sources)

- [1]Early Labor Posterior Uterine Wall Rupture in a Primigravid Mother with Successful Repair and Live Birth: A Case Report.Case reportSisay A, Teshome A, Regasa E, Siferih M. (2024) · DOI: 10.2147/ijwh.s439619

## 임상 시나리오

Clinical Practice Guide: Emergency Management of Suspected Uterine Rupture

Immediate Recognition

The classic clinical triad includes acute onset of severe, tearing abdominal pain, sudden fetal bradycardia, and maternal signs of shock (hypotension, thready pulse). This is an obstetric emergency requiring a coordinated, rapid response.

Priority Actions

- **Activate the emergency response system** and notify the obstetrician, anesthesiologist, and surgical team immediately. The goal is to achieve a decision-to-delivery interval of less than 30 minutes.

- **Prepare for immediate cesarean delivery.** This is the only definitive intervention. While preparing, simultaneously initiate resuscitative measures.

- **Stop all uterotonic agents** (e.g., oxytocin) to reduce uterine activity and potential further damage.

- **Initiate maternal resuscitation:** Administer high-flow oxygen via a non-rebreather mask, insert two large-bore IV catheters, and begin rapid fluid resuscitation with crystalloids or blood products as ordered.

- **Position the client** in a left lateral tilt to improve venous return and placental perfusion, if it does not delay transport to the operating room.

Key Nursing Considerations

- Do not delay surgical preparation for diagnostic tests. The diagnosis is primarily clinical.

- Assign a team member to provide clear, calm communication to the client and family about the need for emergency surgery.

- Anticipate the need for massive transfusion protocol activation and prepare for potential neonatal resuscitation.

- Document the time of symptom onset, interventions, and team notifications precisely.

## 핵심 개념

- **Uterine Rupture** — Uterine rupture. A complete or incomplete tear in the muscular wall of the uterus during pregnancy or labor, a life-threatening emergency that can allow the fetus to escape into the abdominal cavity.
- **Fetal Bradycardia** — Fetal bradycardia. A condition where the fetal heart rate persistently drops below 110 bpm. It is one of the major signs of uterine rupture and indicates fetal distress.
- **Oxytocin** — Oxytocin. A hormone (drug) used to induce and maintain uterine contractions. Excessive stimulation is a major risk factor for uterine rupture, and it must be stopped immediately if suspected.
- **Left Lateral Position** — Left lateral recumbent position. A position taken by pregnant women, especially when there is hypotension or fetal distress. It reduces compression of the inferior vena cava, increasing venous return and cardiac output, thereby improving blood flow to the mother and fetus.
- **Emergency Cesarean Delivery** — Emergency cesarean section. A surgical delivery performed rapidly when the life of the mother or fetus is threatened. It is the standard treatment when uterine rupture is confirmed or strongly suspected.

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