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Zorluk: ZorAnte/Intra/Postpartum and Newborn Care

A gravid client at 39 weeks gestation is undergoing a trial of labor after cesarean (TOLAC) while receiving a continuous intravenous oxytocin infusion. The client suddenly cries out, reporting an intense, sharp pain in the lower abdomen that radiates to the right shoulder. The nurse notes that the previously established pattern of regular uterine contractions has abruptly ceased. The fetal heart rate tracing immediately shifts from a baseline of 145 beats/min to a prolonged deceleration of 70 beats/min. The client's current vital signs are: blood pressure 82/45 mm Hg, heart rate 136 beats/min, and respiratory rate 26 breaths/min. Which of the following actions should the nurse perform first?

  1. A
    Document the fetal tracing changes as benign early decelerations resulting from rapid fetal descent through the birth canal.
  2. B
    Delegate the immediate assessment of the client's peripheral perfusion and worsening shock to the unlicensed assistive personnel (UAP).
  3. Immediately stop the oxytocin infusion, initiate rapid intravenous fluid resuscitation, and prepare the client for an emergency laparotomy.Cevap
  4. D
    Elevate the head of the client's bed to a high-Fowler's angle to alleviate the referred shoulder pain and improve respiratory expansion.

Cevap

The correct action is to immediately discontinue the oxytocin infusion, begin rapid intravenous fluid resuscitation, and prepare the client for an emergency laparotomy.
The client's presentation of a sudden, sharp abdominal pain, an abrupt cessation of contractions, referred shoulder pain (Kehr's sign caused by blood pooling under the diaphragm), maternal hypovolemic shock, and severe fetal bradycardia is the classic triad of a complete uterine rupture. This is a catastrophic obstetric emergency. The highest priority is to immediately stop the oxytocin infusion to prevent further uterine stimulation, aggressively treat the hypovolemic shock with rapid intravenous fluids, and prepare the client for a life-saving emergency laparotomy (cesarean delivery and surgical repair).

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1
Identify the clinical triad of symptoms presented in the scenario.
The client has sudden tearing abdominal pain, an abrupt cessation of uterine contractions, and referred shoulder pain (Kehr's sign).
These are the hallmark signs of a complete uterine rupture, a catastrophic complication of a trial of labor after cesarean (TOLAC) where the uterus tears open.
2
Analyze the maternal vital signs and the fetal heart rate tracing.
The maternal vital signs (BP 82/45, HR 136) indicate severe hypovolemic shock due to internal hemorrhage. The fetal prolonged deceleration to 70 beats/min indicates profound fetal distress from loss of uteroplacental perfusion.
The rupture causes massive maternal blood loss into the peritoneal cavity and cuts off the oxygen supply to the fetus, requiring immediate life-saving action.
3
Determine the highest priority nursing intervention.
The immediate priority is to stop the oxytocin (which exacerbates the rupture), restore maternal intravascular volume with IV fluids, and facilitate immediate surgical delivery.
Surgical intervention is the only definitive treatment for uterine rupture to save both the mother and the fetus.

Anahtar Kavram

Uterine rupture is a life-threatening obstetric emergency characterized by severe tearing pain, cessation of contractions, referred shoulder pain, maternal shock, and fetal bradycardia, requiring immediate cessation of oxytocin and emergency surgery.
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Ante/Intra/Postpartum and Newborn Care

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