Uterine Rupture Nursing Management

Uterine rupture in the lower uterine segment.

Description

1. Uterine rupture is tearing of the uterus, either complete (i.e., rupture extends through entire uterine wall and uterine contents spill into the abdominal cavity) or incomplete (ie, rupture extends through the endometrium and myometrium, but the peritoneum surrounding the uterus remains intact).
2. Small tears may be asymptomatic and may heal spontaneously, remaining undetected until the stress and strain of a subsequent labor.

Etiology

1. Traumatic uterine rupture may be caused by injury from obstetric instruments, such as uterine sound or curette used in abortion.
2. Rupture also may result from obstetric intervention, such as excessive fundal pressure, forceps delivery, violent bearing-down, tumultuous labor, and fetal shoulder dystocia.
3. Spontaneous uterine rupture is most likely to occur after previous uterine surgery, grand multiparity combined with the use of oxytocic agents, cephalopelvic disproportion, malpresentation, or hydrocephalus.

Pathophysiology

1. The most common pathologic factor is a pre-existing scar that results in a weakened or defective myometrium that does not stretch; this is most frequently identified in spontaneous uterine rupture.
2. Some episodes of rupture are due to traumatic disruption of the uterine surface.
3. More severe ruptures pose the risk of irreversible maternal hypovolemic shock or subsequent peritonitis, consequent fetal anoxia, and fetal or neonatal death.

Assessment Findings

• Clinical manifestations vary from mild to severe, depending on the site and extent of the rupture, degree of extrusion of the uterine contents, and intraperitoneal evidence or absence of spilled amniotic fluid and blood.

1. Abdominal pain
2. Vaginal bleeding (may be present but is not always)
3. Nonreassuring fetal heart pattern
4. Palpation of fetal parts under the skin
5. Signs of hypovolemic shock (with complete uterine rupture)

Nursing Management

1. Monitor for the possibility of uterine rupture.

• In the presence of predisposing factors, monitor maternal labor pattern closely for hypertonicity or signs of weakening uterine muscle.
• Recognize signs of impending rupture, immediately notify the physician, and call for assistance.

2. Assist with rapid intervention.

• If the client has signs of possible uterine rupture, vaginal delivery is generally not attempted.
• If symptoms are not severe, an emergency cesarean delivery may be attempted and the uterine tear repaired.
• If symptoms are severe, emergency laparotomy is performed to attempt immediate delivery of the fetus and hen establish homeostasis.
• Implement the following preparations for surgery.
  • Monitor maternal blood pressure, pulse, and respirations; also monitor fetal heart tones.
  • If the client has a central venous pressure catheter in place, monitor pressure to evaluate blood loss and effects of fluid and blood replacement.
  • Insert a urinary catheter for precise determinations of fluid balance.
  • Obtain blood to assess possible acidosis.
  • Administer oxygen, and maintain a patent airway.

3. Prevent and manage complications. Take these steps in order to prevent or limit hypovolemic shock:

• Oxygenate by providing 8 to 10 L/min using a closed mask.
• Restore circulating volume using one or more IV lines.
• Evaluate the cause, response to therapy, and fetal condition.
• Remedy the problem by preparing the client for surgery and administering antibiotics.

4. Provide physical and emotional support.

• Provide support for the client’s partner and family members once surgery has begun.
• Inform the partner and family how they will receive information about the mother and newborn and where to wait.