By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 9a: In a patient with clinical evidence of complications in labour (ex: abruption, uterine rupture, shoulder dystocia, nonreassuring fetal monitoring): Diagnose the complication.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Diagnosis
Key Feature 9b: In a patient with clinical evidence of complications in labour (ex: abruption, uterine rupture, shoulder dystocia, nonreassuring fetal monitoring): Manage the complication appropriately. Skill: Clinical Reasoning, Selectivity
In this post I will review some complications that can arise in labour: maternal fever, nonreassuring fetal monitoring, and shoulder dystocia. See other recent posts for the assessment and management of other intrapartum concerns.
Note that my approach to diagnosing and managing abruption and uterine rupture were discussed in my blog post on antenatal complications. They may present with sudden onset constant pain with or without vaginal bleeding and may also present with fetal or maternal compromise. These complications require a high index of suspicion, and if suspected, warrant immediate delivery by C-section.
An intrapartum complication to watch for is maternal fever, as it can be a sign of infection, and of infection of the fetal membranes in particular, called chorioamnionitis. This can increase risk of fetal brain damage and cerebral palsy. It may present with maternal fever, fetal tachycardia, foul vaginal discharge, and uterine tenderness. Differential diagnosis includes nonobstetrical infection such as UTI or respiratory infection, pyrexia due to an overheated room or dehydration, or it may be an epidural-associated reaction. In any case, these other issues may be happening alongside the presence of chorioamnionitis, and since the repercussions of missing it are of significance, it is important to keep a high index of suspicion. The treatment for suspected chorioamnionitis is ampicillin and gentamicin, which should be given until the mom is afebrile for 24h. It would be prudent to call for a Pediatrician to attend the birth.
Nonreassuring fetal monitoring
In the low-risk labour without evidence or risk factors for complications, a less invasive approach to fetal monitoring is preferred so as partly to increase maternal comfort but more importantly to avoid false positive findings that then lead to interventions that can cause harm without any associated benefit. In the low-risk labour, fetal heart rate monitoring is preferably done by intermittent auscultation. If there are almost any risk factors going into labour, however, or if any complicating factors arise during labour including intermittent auscultation that cannot be classified as normal, then instead being on continuous electronic fetal monitoring (EFM) is standard of care. When interpreting an EFM strip, there are a number of variables to consider including fetal heart rate baseline, variability, accelerations, and decelerations, and these are taken into account along with the clinical picture to form an impression of how well or unwell the fetus is coping with labour/delivery. The EFM strip is assessed as normal, atypical, or abnormal. If the strip is normal, smooth sailing. If the strip is atypical, it could indicate the fetus is not doing so well, but the picture is unclear. If the strip is classified as abnormal, urgent action must be taken to gather more info +/- correct any reversible insults, and if the assessment continues to be abnormal, then urgent operative intervention is needed to get the infant delivered as soon as possible.
Shoulder dystocia occurs when, after delivering the fetal head, the rest of the fetus does not delivery after the next contraction, despite applying (gentle) traction. This is because the anterior fetal shoulder is impacted behind the maternal symphysis pubis. Typically the fetal head stays abutting the perineum (aka the “turtle sign”), and there may be failure to restitute. This can feel like a very scary situation, for fear of reduced fetal brain oxygenation, but in between uterine contractions the fetus will likely continue to be well-enough perfused and have the reserve to handle the stress of this situation for a short amount of time. That being said, if shoulder dystocia is suspected, it will be important to stay calm to ensure mom stays calm, and to advise her to relax as much as possible in this anxiety-rousing situation.
Like the management of most emergencies in medicine, there is a common approach to managing shoulder dystocia that is remembered by the help of a mnemonic: ALARMER. Once shoulder dystocia is suspected, the sequence of actions characterized by each letter in the word is attempted until the body of the infant is delivered or until more extreme measures are taken after failure of the ALARMER maneuvers to correct the obstruction. The maneuvers are as follows: Ask for help, Lift/hyperflex the legs (aka McRoberts’ maneuver), Anterior shoulder disimpaction (whereby the heel of a clasped hand applies suprapubic pressure over the location the fetal shoulder to shift it anteriorly and decrease the anterior-posterior diameter; this can also be attempted from an intravaginal approach), Rotation (aka Woods’ corkscrew maneuver, which involves similar efforts to shift the anterior shoulder but while applying force to the posterior shoulder as well, in an attempt to rotate the infant to deliver the anterior shoulder; this is done with the hands applying pressure to the shoulders intravaginally), Manual removal of the posterior arm, Episiotomy (only done to facilitate a better attempt at Woods’ maneuver or manual removal of the posterior arm, because while tissue obstruction can impair the clinician’s ability to carry out these maneuvers, it is never itself the cause of shoulder dystocia), and Roll over onto all fours (this may disimpact the anterior shoulder directly or allow for a better attempt at manual removal of the posterior arm). These maneuvers can be repeated if the infant has not yet been delivered, and are about as much as the low-risk obstetrician would be trained to do. Surgical management by an obstetrician would be needed if the ALARMER maneuvers are to no avail.
See this link for a pdf document by Perinatal Services BC that goes through the ALARMER maneuver with great photos.