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Question

Difficulty: HardLabor, Delivery, and Puerperium

A 33-year-old gravida 2, para 1, at 39 weeks gestation is admitted to the hospital in active labor. Her prenatal course was uncomplicated. Her previous pregnancy resulted in a low transverse cesarean delivery due to breech presentation. She strongly desires a vaginal birth and is undergoing a trial of labor after cesarean. Upon admission, cervical examination shows 5 cm dilation and 90% effacement, with the fetal head at -1 station. Epidural analgesia is administered with excellent effect. Three hours later, the patient suddenly complains of a sharp, tearing lower abdominal pain that radiates to her right shoulder, breaking through the epidural block. Concurrently, the fetal heart rate monitor demonstrates a sudden, prolonged deceleration to 75/min that has persisted for 4 minutes. A repeat cervical examination reveals 5 cm dilation and the fetal presenting part is now palpable at -3 station. Maternal blood pressure is 90/50 mm Hg and pulse is 118/min. Which of the following is the most appropriate next step in management?

  1. A
    Maternal left lateral repositioning and intravenous fluid bolus
  2. B
    Initiation of transcervical amnioinfusion
  3. Emergency laparotomyAnswer
  4. D
    Administration of intravenous terbutaline
  5. E
    Administration of intravenous ephedrine

Answer

Emergency laparotomy
The correct answer is emergency laparotomy. This patient is experiencing a uterine rupture, a life-threatening complication most commonly seen in patients undergoing a trial of labor after a previous cesarean delivery. The classic presentation includes sudden breakthrough abdominal pain, a nonreassuring fetal heart rate tracing (most commonly a prolonged deceleration or bradycardia), maternal hemodynamic instability, and a pathognomonic loss of fetal station as the fetus retracts into the abdominal cavity. Furthermore, blood irritating the diaphragm (hemoperitoneum) commonly causes referred shoulder pain (Kehr's sign). The definitive management is an immediate laparotomy for delivery of the fetus and repair of the uterine defect (or hysterectomy) to control hemorrhage.

Step-by-Step Solution

1
Identify the risk factors and the acute clinical presentation.
The patient is undergoing a trial of labor after cesarean (TOLAC) and presents with acute breakthrough abdominal pain, referred shoulder pain, hypotension, and fetal bradycardia.
Patients with a history of prior cesarean delivery have a uterine scar that is susceptible to tearing under the stress of labor.
2
Analyze the pelvic examination findings.
The fetal presenting part has retracted from -1 station to -3 station.
Loss of fetal station is a pathognomonic sign that the fetus has been extruded through a uterine defect into the maternal abdominal cavity.
3
Determine the definitive management based on the diagnosis of uterine rupture.
Immediate surgical intervention is required.
Uterine rupture causes massive intra-abdominal hemorrhage (hemoperitoneum) and fetal asphyxia, necessitating an emergency laparotomy for delivery and uterine repair.

Key Concept

Recognition and management of uterine rupture during a trial of labor after cesarean (TOLAC)
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Topics

Labor, Delivery, and Puerperium

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