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Difficulty: MediumObstetric Complications

A 31-year-old G2P1 woman at 39 weeks gestation is admitted to the labor and delivery unit for a trial of labor after a prior low transverse cesarean delivery. She is receiving an intravenous oxytocin infusion for labor augmentation. Her most recent cervical examination 1 hour ago showed 7 cm dilation, 90% effacement, and the fetal head at +1 station. The patient suddenly reports intense, tearing lower abdominal pain that radiates to her chest. The intrauterine pressure catheter shows a sudden loss of baseline uterine tone and the cessation of regular contractions. Continuous fetal heart rate monitoring demonstrates a prolonged deceleration to 75/min. On repeat pelvic examination, the cervix is unchanged, but the fetal presenting part is now ballotable at -2 station. Her blood pressure is 85/45 mm Hg, and her pulse is 125/min. Which of the following is the most appropriate next step in management?

  1. Proceed to emergency laparotomyAnswer
  2. B
    Administer intravenous terbutaline
  3. C
    Place the patient in the left lateral decubitus position and administer a fluid bolus
  4. D
    Perform bedside transabdominal ultrasonography
  5. E
    Perform an operative vaginal delivery

Answer

Proceed to emergency laparotomy
The correct answer is to proceed to emergency laparotomy. This patient is experiencing a uterine rupture, a life-threatening obstetric emergency characterized by a full-thickness disruption of the uterine wall. Classic signs include sudden-onset severe abdominal pain, an abnormal fetal heart rate tracing (e.g., prolonged deceleration or bradycardia), a palpable loss of fetal station, and a sudden cessation of uterine contractions. Given the maternal hemodynamic instability (hypotension, tachycardia) and fetal distress, immediate surgical intervention via laparotomy is required to deliver the fetus, control the hemorrhage, and repair the uterus.

Step-by-Step Solution

1
Evaluate the patient's acute symptoms and vital signs.
The patient has severe, tearing abdominal pain, hypotension (85/45 mm Hg), and tachycardia (125/min).
To identify hemodynamic instability suggesting massive internal hemorrhage.
2
Analyze the fetal and uterine monitoring data.
There is a prolonged fetal bradycardia (75/min), loss of uterine tone, and cessation of contractions on the intrauterine pressure catheter.
To determine the cause of fetal distress and maternal pain.
3
Assess the change in pelvic examination findings.
The fetal station has changed from +1 to -2 (loss of fetal station).
Loss of station is a pathognomonic sign of uterine rupture, as the fetus extrudes into the abdominal cavity.
4
Determine the most appropriate management.
Immediate surgical intervention via laparotomy is indicated.
Uterine rupture with maternal hemodynamic instability and fetal distress requires emergent delivery and surgical repair to prevent maternal and fetal mortality.

Key Concept

Diagnosis and management of uterine rupture
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Topics

Obstetric Complications

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