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Difficulty: EasyObstetric Complications

A 33-year-old gravida 3, para 2 at 38 weeks gestation presents to the labor unit with painful, regular uterine contractions. Her obstetric history is notable for a primary low transverse cesarean delivery three years ago. She is currently undergoing a trial of labor. Several hours into her admission, the patient suddenly screams in agony, describing a severe, tearing pain in her lower abdomen that persists between contractions. Concurrently, the electronic fetal monitor displays a sudden and sustained fetal bradycardia of 75/min. Vaginal examination shows that the fetal presenting part, previously at +1 station, can no longer be palpated. Her blood pressure drops to 85/50 mm Hg. Which of the following is the most appropriate next step in management?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Maternal repositioning and amnioinfusion
  3. C
    Administration of intravenous oxytocin
  4. D
    Emergency obstetric forceps application
  5. E
    Bedside pelvic ultrasound

Answer

Immediate exploratory laparotomy
This patient's sudden onset of severe, tearing abdominal pain, profound fetal bradycardia, and loss of fetal station in the setting of a prior cesarean delivery are pathognomonic for uterine rupture. The massive hemorrhage into the abdomen rapidly causes maternal hemodynamic instability. The most appropriate next step is an immediate exploratory laparotomy to deliver the fetus, control the bleeding, and repair or remove the ruptured uterus.

Step-by-Step Solution

1
Analyze the patient's presentation and obstetric history
The patient has sudden, tearing abdominal pain, severe fetal bradycardia, and maternal hypotension in the setting of a prior cesarean delivery.
Identifying these classic risk factors and symptoms points toward a catastrophic structural failure of the uterus.
2
Evaluate the physical examination findings
The fetal presenting part has retracted and can no longer be palpated on vaginal examination.
Loss of fetal station indicates the fetus has extruded through the uterine wall into the abdominal cavity, confirming the diagnosis of uterine rupture.
3
Determine the most appropriate next step in management
Immediate exploratory laparotomy is required.
Uterine rupture causes life-threatening hemorrhage and fetal hypoxia, necessitating rapid surgical delivery and hemorrhage control without delay for imaging.

Key Concept

Diagnosis and emergent surgical management of uterine rupture
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Topics

Obstetric Complications

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