A nurse is caring for a client who is in a trial of labor for vaginal birth after cesarean (VBAC). The client reports a sudden tearing pain in their back and side that does not feel like a uterine contraction.
Which of the following findings indicates the client may be experiencing a uterine rupture?

• Discontinue oxytocin infusion (Expected): The client has contractions every 1–2 minutes lasting 90–120 seconds, indicating uterine tachysystole. Stopping oxytocin is a primary intervention to reduce contraction frequency and duration, preventing further fetal hypoxia.
• Assist with amnioinfusion (Expected): Amnioinfusion can help dilute thick meconium-stained amniotic fluid or relieve cord compression, which can cause late decelerations and minimal variability in FHR. It is often used to improve fetal oxygenation during uterine hyperstimulation.
• Give 500 mL of lactated Ringer’s IV bolus (Expected): Increasing maternal hydration improves uteroplacental perfusion, which can be compromised during frequent contractions. This intervention helps restore blood volume and oxygen delivery to the fetus.
• Place the client in a side-lying position (Expected): Lateral positioning improves uterine blood flow by relieving pressure on the vena cava and optimizing cardiac output and fetal oxygenation.
• Give betamethasone 12 mg IM now (Unexpected): Betamethasone is administered antenatally to accelerate fetal lung maturity in preterm labor (before 34 weeks). This client is at 38 weeks gestation, so corticosteroids are not indicated.

The client is at greatest risk for developing Endometritis as evidenced by the client’s Lochia characteristics.

Rationale for correct answers:
Endometritis is a postpartum uterine infection commonly occurring after cesarean birth due to ascending bacterial contamination. The client’s foul-smelling lochia is a hallmark sign, indicating infection of the uterine lining. Normally, lochia is odorless and changes from red to serous and then to white over weeks postpartum. The elevated WBC count (18,000/mm³; normal 5,000–15,000/mm³) supports infection but is nonspecific. The firm uterine tone reduces likelihood of postpartum hemorrhage. Urinalysis positive for bacteria suggests UTI but does not explain uterine signs. Hence, lochia changes are the most direct indicator of endometritis.

Rationale for incorrect Response 1 answers:
Postpartum hemorrhage typically involves heavy bleeding, uterine atony, or a rapidly dropping hematocrit, none of which is reported here. Urinary tract infection is suggested by urinalysis but does not account for uterine tenderness or foul lochia. Deep vein thrombosis would present with limb swelling, pain, and possible fever but no uterine or lochia changes.

Rationale for incorrect Response 2 answers:
Urinalysis positive for bacteria points to UTI but not uterine infection. Elevated WBC count indicates infection or inflammation but lacks specificity for endometritis versus other infections. Uterine tone is firm here, making hemorrhage or uterine atony unlikely and less relevant to infection diagnosis.

Take home points:

• Endometritis often presents postpartum with foul-smelling lochia and elevated WBC.
• Foul-smelling lochia is a critical clinical sign distinguishing endometritis from other postpartum complications.
• Positive urinalysis suggests UTI, a separate postpartum infection that requires differentiation.
• Uterine tone helps rule out hemorrhage and guides diagnosis of infection versus atony.