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Re: vbacFrom: Anna Nickels (102476.2066@compuserve.com)Mon Mar 11 16:12:30 1996
One of the scariest moments I ever had as a labor nurse involved a uterine rupture. My patient was a G2P1 tolac (trial of labor after c/s) and had progressed slowly but without difficulty to c/c. She had oxytocin running at 6mu/min, an effective epidural, and a reassuring tracing. UCs were running about 55mm/Hg q2-3. I coached her in pushing technique, we did one (1) trial push, and I went to the station to phone the MD (in the sleep room) that we were going to start pushing. When I reentered the room, the pt. said that she couldn't understand why she felt "crampy" since the epidural had been working so well. I asked her to point to the site of her "cramp" and she put her finger right on the midline of her transverse scar. When I touched it to confirm whether she had dermal sensation, there was a nickel-sized area that felt like jello directly under the skin. By the end of that contraction, the area was about 4cms, I was on the emergency call light, and the IUPC was already monitoring a lack of tone. Before the MD and anesthesia got there (50 yards away), I had the terb on board, was inserting a foley (no output, there was no bladder), and the fluid under the skin was about 18 inches in diameter. We went to the OR, poured on solution, and cut. Let me tell you that it was really eerie to be able to see that infant right through the skin and when we opened, the kiddo popped out. The fluid pocket extended all the way up to her nipples. We used 52 sutures and about 100 laps. The bladder required extensive repair, the uterus was saved (only the scar gave way), baby did great, mom spent a long time on antibiotics, and came back to us to have a REPEAT C/S <G> about 20 months later. I was sure that lightening couldn't strike twice and I'd had my turn at white knuckle delivery. In reality, two other pts. I cared for at a small Level 1 hospital had partial dehiscence of the scar. One was a scheduled repeat C/S who came in in labor. Her doc thought we might be able to do a vbac, but she developed q1.5min ucs and couldn't tolerate it. FHR was funky already so he decided on a "vaginal bypass". When he got to the uterus, you could see right through to the baby's face. The second one was actually also a tolac who got stuck at about 7cms. and began to have heavier bleeding than I liked. When I examined her, I thought that the front of the cervix felt really strange (almost ragged) so called the doc. When he checked her, we went to c/s. She had dehisced along the back of the scar and was getting very thin. Thanks for letting me go on so long. I am glad I could provide some clinical information from a nurse's point of view. Anna Romig Nickels, RNC, BSN Washington, DC
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