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Enferm Clin. 2016;xxx(xx):xxx---xxx

www.elsevier.es/enfermeriaclinica

NURSING CARE

Assessment, delivery and peripartum care in the case

of a uterine rupture during labor of a woman with a
previous C-section夽
Alberto Parrilla-Fernández ∗ , Javier Manrique-Tejedor, M. Inmaculada Figuerol-Calderó,
Verónica García-Romero

Servicio de Partos-Obstetricia, Hospital Universitario Arnau de Vilanova, Lleida, Spain

Received 8 December 2015; accepted 11 August 2016

KEYWORDS Abstract Uterine rupture is a rare but severe complication in obstetrics. A previous C-section
Uterine rupture; is the most important risk factor. Its incidence during labor in women with a previous C-section
Repeated C-section; is of approximately 0.3---0.47%, being potentially severe.
Nursing care We present the case of a pregnant women with a previous C-section who suffered uterine
rupture during labor. The rapid assessment and action of the midwife and obstetric team was
essential to obtain a successful obstetric outcome, avoiding maternal and foetal mortality; and
nursing care given to the mother and the newborn after birth contributed to achieving a normal
postpartum.
It is necessary to have specific knowledge about this condition that, despite rare, can present
insidiously with a potential risk for the mother and the foetus.
© 2016 Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Valoración, atención al parto y cuidados periparto en un caso de rotura uterina
Rotura uterina; en trabajo de parto tras cesárea anterior
Cesárea repetida;
Cuidados de Resumen La rotura uterina es una complicación rara pero grave en obstetricia. La cesárea
enfermería previa es el factor de riesgo más importante. Su incidencia durante el trabajo de parto en
mujeres con una cesárea anterior es aproximadamente de 0,3-0,47%, siendo potencialmente
grave.

夽 Please cite this article as: Parrilla-Fernández A, Manrique-Tejedor J, Figuerol-Calderó MI, García-Romero V. Valoración, atención al parto

y cuidados periparto en un caso de rotura uterina en trabajo de parto tras cesárea anterior. Enferm Clin. 2016. http://dx.doi.org/10.1016/
j.enfcli.2016.08.005
∗ Corresponding author.

E-mail address: a.parrilla90@gmail.com (A. Parrilla-Fernández).

http://dx.doi.org/10.1016/j.enfcle.2016.08.001
2445-1479/© 2016 Elsevier España, S.L.U. All rights reserved.

ENFCLE-622; No. of Pages 6

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Se presenta un caso de una gestante, con antecedentes de cesárea anterior, que sufre una
rotura uterina en trabajo de parto. La rápida valoración y actuación de la matrona y del equipo
obstétrico fue imprescindible para obtener un resultado obstétrico satisfactorio, evitando la
mortalidad materna y fetal, y los cuidados de enfermería realizados en el posparto a la madre
y al recién nacido contribuyeron a conseguir un puerperio normal.
Es necesario poseer conocimientos específicos sobre esta afección, que aun siendo rara, puede
producirse de manera insidiosa con potencial riesgo para madre y feto.
© 2016 Elsevier España, S.L.U. Todos los derechos reservados.

Introduction Signs and symptoms of intrapartum UR are abdomi-

Uterine rupture (UR) is defined as the discontinuity of
the uterine wall. It is one of the most serious obstetric
complications due to its high maternal and foetal morbid-
ity and mortality. Uterine perforations produced by surgical
procedures are excluded.1
Its incidence during birth in women with a previ-
ous caesarean section (C-section) in western countries is
approximately 0.3---0.47%; UR without previous scarring is
extremely rare, with an estimated occurrence of 0.7 in each
10,000 births.1---3 That is why it is important to inform the
expectant mother about the advantages and risks of a vagi-
nal delivery if there is a history of C-section4---7 and to follow
a series of recommendations to prevent UR (appropriate
delivery control in a centre permitting emergency C-section
and foetal monitoring using continuous foetal cardiotocogra-
phy (CTG)5,6 [grade B recommendation], appropriate use of
oxytocin, avoiding deliveries, traumatic manoeuvres, fundal
pressure and the use of misoprostol).1,8
Two different types can be differentiated:
(1) Incomplete rupture: This is a segmented rupture
that preserves the visceral peritoneum intact, with-
out expelling the intrauterine content. It is not usually
associated with maternal or foetal complications and is
frequently found during the course of a C-section.2,9
(2) Complete rupture: This is the haemorrhagic tearing
of the uterine wall with rough edges and of variable
direction. As the uterine cavity communicates with the
abdominal, the foetus can be found in the abdomi-
nal cavity. It is frequently accompanied by maternal
haemorrhage and severe foetal complications. It is most
commonly found in the lower segment.9
In expectant mothers that have had a prior C-section, the
rate of maternal mortality is 4/100,000 in vaginal delivery
vs 13/100,000 in programmed C-section, while the rate of
perinatal mortality is 0.13% in vaginal delivery vs 0.05% in
programmed C-section.5
The rate of success for vaginal delivery after a previous
C-section is 72---76%.5,10
The most important risk factors are as follows: pre-
vious uterine intervention (principal risk), high parity,
advanced maternal age, macrosomia, multiple birth, uterine
abnormality, lengthy birth, obstetric interventions, fun-
dal pressure, maternal diseases and anomalous placenta
insertion.7,11---13
nal pain, foetal bradycardia or CTG alterations, maternal
tachycardia, cessation of uterine contractions, haematuria,
vaginal bleeding and elevation of foetal presentation.1,3,14
In contrast, attempting a vaginal delivery is advised in
cases of a previous low transversal C-section. Likewise,
vaginal delivery can be recommended in cases of diabetes
mellitus, short birth interval, lengthy gestation and twin
birth. Oxytocin and dinoprostone can be used in these
deliveries.6
Case presentation
We present a case of intrapartum UR in a 32-year-
old women, parity (TPAL) 1011 (prior C-section in 2012
and abortion in 2015), no known allergies or harmful
habits. The patient had a personal history of migraine and
hypothyroidism, a surgical intervention for breast reduction,
C-section and dilation and curettage.
Assessment stage
The expectant mother came to Emergency Obstetric Ser-
vices at 00:30 h because of regular uterine dynamics of
3 h of development, as well as hydrorrhea during the pre-
vious 30 min, without metrorrhagia. Patient history was
taken. Gestational control was correct and the course of
the pregnancy was normal. Treatment during the preg-
nancy consisted of folic acid 400 ␮g/day and levothyroxine
75 mg/day. The most relevant information from the current
pregnancy consisted of an A negative blood group, nega-
tive blood tests, low combined risk, negative gestational
diabetes screening and negative Streptococcus agalactiae
vaginal-rectal culture. In the third trimester sonogram, the
placenta showed normal posterior insertion, the amniotic
fluid index was normal and the percentile was 79.
Diagnostic stage
After taking the history, a CTG was performed. The obstet-
ric assessment showed a diffuse centred cervix dilated to
4 cm, with a torn amniotic sac and clear fluid, cephalic pre-
sentation. It was decided to admit the patient for birth in
progress and she was put in the dilation room.
At 2:00 h epidural analgesia was given, without any
complications.
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Assessment, delivery and peripartum care in the case of a uterine rupture
Table 1 Evolution of the analyses.
Hgb
Third trimester analyses 10.9
Intraoperative 7.3
Intraoperative after 2 units of packed red blood cells 9.7
Postoperative 11.1
6 h postpartum 10.7
Day 4 postpartum 10.3
At 3:45 h, after labor did not advance, the gynaecologist
on call was notified. Patient was administered a perfusion
of 5 IU oxytocin diluted in 500 ml of physiological saline at
7 ml/h. Reassuring CTG. Uterine dynamics were 2 contrac-
tions every 10 min and irregular.
At 4:15 h the oxytocin perfusion was increased to 15 ml/h.
Reassuring CTG. Uterine dynamics: 3 contractions every
10 min, regular.
A 5:45 h an intermittent vesicle probe and vaginal exam-
ination were performed; dilation was 8---9 cm. Various blood
clots were expelled; the gynaecologist on call was notified
again and an internal dynamic sensor was placed on the
anterior side of the uterus. Reassuring CTG.
At 6:55 h there were several foetal heart decelerations
late or offset with respect to the contractions (DIP II),
accompanied by sudden profound abdominal pain in the
hypogastrium, mesogastrium and left flank, which did not
pass in spite of the epidural perfusion. An emergency call
was issued for the gynaecologist on call.
Planning-intervention stage
At 7:00 h emergency C-section was begun due to risk for loss
of foetal well-being and suspected UR. Patient was given
preoperative preparation, inserting a size 16 Foley blad-
der catheter, administering citrate orally and shaving the
abdominal area.
An emergency C-section was performed, a live male of
3560 g being born at 7:10; APGAR score was 0---10, venous
pH was 7.20 and arterial, 7.13; no resuscitation procedures
were necessary.
A UR of the entire anterior scar was found. The UR
continued in a left angle towards the lateral-inferior side,
with a wide haematoma of the uterosacral ligament, left
infundibulum and towards the retroperitoneal space. There
was abundant bleeding, impossible to stop; an emergency
subtotal hysterectomy with left adnexectomy was conse-
quently performed, notifying the patient and the family.
Urgent intraoperative analyses were performed, with the
result being haemoglobin 7.3 and haematocrit 22.7. Conse-
quently, 4 units of packed red blood cells were administered
to stabilise the patient. The analytic data during admission
are presented in Table 1.
The hysterectomy was finished without any complications
and the patient was stable, with normal vital signs and
good diuresis. After the patient was moved to the postop-
erative recovery room, the values for haemoglobin (11.1)
and haematocrit (33.7) increased. In that period, the new-
born was put in skin-to-skin situation and breastfeeding was
3
Hcrt Platelets Haemostasis Gasometry pH pCO2 pO2
36.1 267,000 Normal
22.7 144,000 Normal 7.40 27 252
30 155,000 Normal 7.23 37 339
33.7 164,000 Normal 7.29 32 143
32.5 186,000 Normal
30.8 196,000 Normal
then initiated. After 4 h the patient was transferred to the
hospital ward.
During the first postoperative day, the patient was kept
on only fluids, with serum therapy and bladder catheter.
Vital signs fell within normal; patient had blood-serum
drainage of approximately 80 cc and pain was controlled by
the scheduled analgesia. Maternal breastfeeding was suc-
cessful.
During the second day, vital signs continued normal and
general state was good; abdomen was soft and yielding
to touch with no signs of peritoneal irritation, there was
20 cc of drainage and good diuresis. The surgical wound was
treated, oral tolerance was initiated and the saline drip,
bladder catheter and drainage were removed. During the
third day, vital signs were normal and patient showed good
evolution, with proper diuresis and good oral tolerance.
On the fourth day, a control analysis was performed, with
the results falling within normal ranges. The patient showed
a good general state and began oral iron treatment.
On the fifth day, the patient was given anti-D gamma
globulin. Her vital signs were normal, with soft yielding
abdomen and normal lochia. Consequently, the decision was
made to discharge the patient, with follow-up in her health-
care centre with the midwife and the gynaecologist.
As for the newborn, the neonatologist performed the
post-delivery assessment and aspirated the child’s upper
respiratory tract; despite the pH values of the umbilical
cord blood, the newborn responded well to the adaptation to
extra-uterine life. He was placed in contact with the father’s
skin until the end of the surgical intervention. Standard pro-
phylaxis was later performed and the newborn did not need
any special attention during admission. The baby continued
with maternal breastfeeding and no additional supplement
was required.
Result appraisal stage
The patient history and obstetric assessment upon admis-
sion was correct and complete. Labor evolved without any
abnormal signs until the moment when the blood clots were
expelled. Given the total normality of the CTG, the lack of
abnormal signs and the rapid dilation of the cervix (which
can be compatible with and a reason for expelling clots),
it was decided to continue with the evolution of the labor,
with strict follow-up.
As soon as DIP II was detected in the CTG and UR was
suspected, the actions taken were quick and according to
protocols.
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4 A. Parrilla-Fernández et al.

Table 2 Comparison of basic needs, nursing diagnoses, NIC and NOC.

Need Nursing diagnosis Results (NOC) Interventions (NIC) Activities
(NANDA)
1. Breathing Risk for aspiration NOC 2303 NIC 3140 314002
(00039) Post-procedure Airway management Place the patient to maximise
Risk factors recovery breathing potential
Reduced level of
consciousness
Endotracheal
intubation
2. Eating/drinking Risk for electrolyte NOC 0601: NIC 4130: 413002:
imbalance (00195) Fluid balance Fluid monitoring Identify possible risk factors for
Risk factors NOC 0602: NIC 4180: fluid imbalance
Fluid imbalance Hydration Hypovolemic 418002:
management Monitor haemodynamic state,
including heart rate, BP, MBP, CVP,
PAP, GC and IC, as available
418008:
Monitor the presence of laboratory
data on blood concentration
3. Eliminating body Disposition to NOC 0503: NIC 0590: 59005:
wastes improve urinary Urinary Urinary elimination Record the hour of the last urinary
elimination (00166) elimination management elimination, as applicable
59009:
Refer to physician if signs and
symptoms of urinary tract infection
arise
59015:
Record the hour of the first
urination after procedures, as
applicable
4. Mobility/posture Impaired physical NOC 2102: NIC 1400: 40001:
mobility (00085) Pain level Pain management Carry out a detailed pain
Risk factors assessment that includes location,
Anxiety characteristics,
Pain appearance/duration, frequency,
quality, pain intensity or severity
and triggering factors
140003:
Ensure the patient receives the
applicable analgesic care
140011:
Help the patient and the family to
obtain and provide support
8. Hygiene/tissue Impaired tissue NOC 1102: NIC 4020: 402001:
integrity integrity (00046) Wound healing: Reduction of Identify the cause of the
primary intention haemorrhage haemorrhage
NIC 3660: 402004:
Wound care Record the
NIC 3662: haemoglobin/haematocrit level
Wound care: closed before and after blood loss
drainage 402013:
Maintain permeable iv access
366014:
Maintain a sterile bandage
technique when giving wound care
366202:
Record drainage volume and
characteristics
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Assessment, delivery and peripartum care in the case of a uterine rupture
Table 2 (Continued)
Need Nursing diagnosis Results (NOC)
(NANDA)
9. Avoiding dangers Risk for shock (00205) NOC 0419:
Shock severity:
hypovolemic
NOC 1908:
Risk detection
NOC 2114:
Hypotension
severity
The result was satisfactory for the patient (despite the
need for performing a hysterectomy) and the newborn (in
spite of the acidosis detected in the pH of the umbilical
cord blood sample). Neither of them needed extraordinary
treatments to maintain their safety.
Nursing evaluation according to Henderson’s
14 basic needs
1. Breathing: During labor, eupnoea; during the C-section,
intubation; following the operation, extubation. The
rest of the time, without any alterations.
2. Eating/hydration: During labor and after the C-section,
the patient was kept on fluids only, with active saline
drip. At 30 h postoperative, oral tolerance initiated,
without any problems.
3. Eliminating body wastes: During labor, bladder elim-
ination produced by intermittent bladder catheters;
once the C-section was indicated, a permanent catheter
was inserted, removing it at 33 h post-caesarean; the
first spontaneous urination occurred 10 h after catheter
removal.
4. Mobility/posture: During labor, due to the epidural
analgesia, mobility was reduced to posture changes in
the bed. At 26 h postoperative, patient began to have
autonomous mobility.
5. Sleeping/resting: The patient did not indicate any alter-
ations.
6. Dressing/undressing: The patient was autonomous.
7. Body temperature: Body temperature was normal dur-
ing the entire process.
8. Hygiene/tissue integrity: The surgical wound in the
abdominal area was treated regularly. The serum-blood
drainage was removed at 33 h post-caesarean.
9. Avoiding dangers: The patient was accompanied by
her partner throughout the entire process. Upon wak-
ing from the operation in the postoperative recovery
room, she found herself with her partner and the new-
born. There was total bed rest during the initial hours
5
Interventions (NIC) Activities
NIC 4260: 426021:
Shock prevention Administer iv and/or oral fluids,
NIC 4030: depending on the case
Administration of 426022:
blood products Canalise and maintain a large-size
NIC 4140: iv pathway, as applicable
Fluid replacement 426024:
Administer packed red cells, frozen
fresh blood and/or platelets, as
applicable
403010:
Perform venipuncture with the
appropriate technique
403022:
Record volume transfused
following the operation. The patient knew about the
situation through which she was passing at all times.
10. Communicating/social relationships: Patient commu-
nicated with her family via cell phone; after the
operation, she could begin to receive visitors after
admission to the hospital ward.
11. Values/beliefs: There were no alterations.
12. Self-fulfilment: There were no alterations.
13. Recreation: The patient had a television available in
her room and had her cell phone and portable com-
puter when she was on the ward, in addition to multiple
visitors.
14. Learning: The patient knew about the situation at all
times; before any intervention was carried out, the
appropriate professional informed her and answered
any doubts (Table 2).
Discussion and conclusion
It is sometimes hard to make an early diagnosis of a UR dur-
ing labor, especially because pain is masked by the effects
of the epidural anaesthesia in the majority of the cases.
For that reason, the midwife that attends the birth process
needs to act rapidly, correctly and decisively. Knowing how
to recognise the signs and symptoms of a UR can be crucial
in avoiding a situation of danger for the mother and for the
foetus.
An important aspect in the cases where there is risk for
UR (as is the case of patients with a previous C-section)
is appropriate management of labor, given that adequate
attention in labor can reduce the incidence of UR. The mid-
wife and obstetrician have to know about the advantages
and possible complications of a vaginal delivery after a prior
caesarean and inform the expectant mother of these.
A great majority of the clinical cases published usually
coincide with this one in the presence of risk factors, espe-
cially the history of previous uterine surgery. In the absence
of this history, URs are usually due to circumstances such as
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6 A. Parrilla-Fernández et al.
the anomalous formation, type or structure of the placenta,
and do not always happen during labor.
The clinical action taken in this case was in accordance
with the scientific recommendations (appropriate, pruden-
tial use of oxytocin, continuous CTG, detailed monitoring,
etc.). Consequently, the midwife in charge of the pregnant
woman was able to detect the signs of UR at an early stage
and communicated this to the gynaecologist on call prop-
erly; therefore, rapid attention was made possible, avoiding
a potentially catastrophic outcome such as maternal and
foetal death. Thanks to the speed of action and the col-
laboration of the entire team, the obstetric result was
satisfactory.
Conflict of interest
The authors have no conflicts of interest to declare.
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