UTERINE RUPTURE

.

Disruption of the uterine wall any time beyond the 28
th
weeks of pregnancy
is called Rupture Uterus.

Dissolution in the continuity of the Uterine wall any time beyond 28
th
weeks
of pregnancy is called rupture of the Uterus.
-It is an Obstetrical emergency.
-Incidence :- Widely varies from 1 in 2000 to 1-200 deliveries.
-Types :-
-1) Complete rupture : All the three layers of the uterus are involved.
-2) Incomplete Rupture: Peritoneum remain intact.
UTERINE RUPTURE
A spontaneous or traumatic rupture of the uterus
ie., the actual separation of the uterine
myometrium/ previous uterine scar, with rupture of
membranes and extrusion of the fetus or fetal parts
into the peritoneal cavity.
Dehiscence is the partial separation of the old
uterine scar; the fetus usually stays inside the
uterus and the bleeding is minimal when
dehiscence occurs.

Ruptured uterus
RISK FACTORS:


Women who have had previous surgery on the uterus (upper muscular portion)
Having more than five full-term pregnancies
Having an overdistended uterus (as with twins or other multiples)
Abnormal positions of the baby such as transverse lie.
Use of Pitocin (oxytocin) and other labor-induced medications (prostaglandin)
Rupture of the scar from a previous CS delivery/hysterectomy.
Uterine/abdominal trauma
Uterine congenital anomaly
Obstructed labor; maneuvers within the uterus
Interdelivery interval (time between deliveries)

Women who have had previous surgery on the uterus (upper muscular portion)
Having more than five full-term pregnancies
Having an overdistended uterus (as with twins or other multiples)
Abnormal positions of the baby such as transverse lie.
Use of Pitocin (oxytocin) and other labor-induced medications (prostaglandin)
Rupture of the scar from a previous CS delivery/hysterectomy.
Uterine/abdominal trauma
Uterine congenital anomaly
Obstructed labor; maneuvers within the uterus
Interdelivery interval (time between deliveries)
Pathologic retraction ring occurs, strong uterine
contractions w/o cervical dilatation
tearing sensation
Complete rupture
Incomplete rupture
Rupturing of endometrium,
myometrium and perimetrium
Rupturing of endometrium
and myometrium
Uterine contraction stops
Localized tenderness and
persisting aching pain over the
area of the uterine segment
Swelling of the abdomen:
Retracted uterus
Extrauterine fetus
Hemorrhage from torn uterine
arteries
Bleeding into the peritoneal cavity
Bleeding to the vagina
Decreased blood volume
Decreased venous return
Decreased cardiac output
Decreased BP
Heart attempts to circulate
remaining blood volume
Vasoconstriction of peripheral
vessels, increased heart rate
Cold, clammy skin
Increases gas exchange to
oxygenate better the decreased
blood volume
Increased respiratory rate
Continued blood loss will continue
to fall BP
Uterine perfusion is decreased
Fetal distress
Decreased brain perfusion
Decreased kidney perfusion
Decreased LOC (lethargy, coma)
Decreased urine output
Renal failure
Death of Mother and fetus
Evaluate maternal vital signs; especially note an
increase in rate and depth of respirations, an
increase in pulse , or a drop in BP indicating
status change.
Observe for signs and symptoms of impending
rupture (ie, lack of cervical dilatation, tetanic
uterine contractions, restlessness, anxiety,
severe abdominal pain, fetal bradycardia, or late
or variable decelerations of the FHR).
Assess fetal status by continuous monitoring.
Speak with family, and evaluate their
understanding of the situation.
SIGNS AND SYMPTOMS:
Clinical Manifestations
Clinical manifestations depend on the type of rupture, with the possibility
that the clinical picture may develop over several hours.

Developing Rupture
Abdominal pain and tenderness
Uterine contractions will usually continue but will diminish in intensity and tone.
Bleeding into the abdominal cavity and sometimes into the vagina.
Vomiting
Syncope; tachycardia; pallor
Significant change in FHR characteristics usually bradycardia (most significant sign)


Violent Traumatic Rupture


Sudden sharp abdominal pain during or between contractions.
Abdominal tenderness
Uterine contractions may be absent, or may continue but be diminished in intensity
and cord
bleeding vaginally, abdominally, or both
Fetus easily palpated in the abdominal with shoulder pain
Tenses, acute abdominal with shoulder pain
Signs of shock
Chest pain from diaphragmatic irritation due to bleeding into the abdomen.

NURSING DIAGNOSIS AND
INTERVENTIONS:
Deficient Fluid Volume related to active fluid loss from
hemorrhage
Start or maintain an IV fluid as prescribed. Use a large gauge catheter when
starting the IV for blood and large quantities of fluid replacemnt.
Maintain CVP and arterial lines, as indicated for hemodynamic monitoring.
Maintain bed rest to decrease metabolic demands.
Insert Foley catheter, and moniter urine output hourly or as indicated.
Obtain and administer blood products as indicated.

Fear related to surgical outcome for fetus and
mother
Give brief explanation to the woman and her support person before beginning a
procedure.
Answer questions that the family or woman may have.
Maintain a quiet and calm atmosphere to enhance relaxation.
Remain with the woman until anesthesia has been administered; offer support as
needed.
Keep the family members aware of the situation while the woman is in surgery and
allow time for them to express feelings.

Ineffective Tissue Perfusion, Maternal Vital
Organ and Fetal r/t Hypovolemia

Administer O2 using a face mask at 8-12 L/min or as ordered to provide high
oxygen concentration.
Apply pulse oximeter, and monitor oxygen saturation as indicated.
Monitor ABG levels and serum electrolytes as indicated to assess respiratory
status, observing for hyperventilation and electrolyte imbalance.
Continually monitor maternal and fetal vital signs to assess pattern because
progressive changes may indicate profound shock.
Fear r/t Surgical Outcome for Fetus and Mother

Give a brief explanation to the woman and her support person before beginning the
procedure.
Answer questions that the family and woman may have.
Maintain a quiet and calm atmosphere to enhance relaxation.
Remain with the woman until anesthesia has been administered; offer support as
needed.
Keep the family members aware of the situation while the woman is in surgery and
allow time for them to express feelings.

Risk for Infection related to surgical incision
Observe for localized signs of infection.
Cleanse incision or insertion sites daily and PRN with povidone iodine or other
appropriate solutions.
Change dressings as needed or indicated.
Encourage early ambulation, deep breathing, coughing and position changes.
Maintain adequate hydration and provide.
Provide perineal care.
:

Immediate stabilization of maternal hemodynamics and
immediate caesarean delivery
Oxytocin is given to contract the uterus and the replacement .

After surgery, additional blood, and fluid replacement is
continued along with antibiotic theory.
SURGICAL
MANAGEMENT:
Caesarean Section
Laparotomy
Hysterectomy
NURSING
MANAGEMENT:
Continually evaluate maternal vital signs; especially
note an increase in rate and depth of respirations, an
increase in pulse , or a drop in BP indicating status
change.
Assess fetal status by continuous monitoring.
Speak with family, and evaluate their understanding of
the situation.
Anticipate the need for an immediate caesarean birth
to prevent rupture when symptoms are present.
Provide information to the support person and inform
him or her about fetal outcome, the extent of the
surgery and the womans safety.
Let the pt express her emotion without feeing
threatened.