Emergencies During Labour and Prolonged Second Stage

Fetal distress

Cord prolapse

Shoulder dystocia

Poor progress in the second stage

FETAL DISTRESS

Fetal distress is suspected when any of the following signs are observed:

• Baseline fetal heart rate >160 beats per minute
• Baseline fetal heart rate <110 beats per minute
• Baseline variability persistently ≤5 beats per minute on CTG (in the absence of sedating drugs)
• Late decelerations of the fetal heart rate
• Persistent severe or atypical variable decelerations
• Thick meconium staining of the liquor

Management of fetal distress

1. Explain the problem to the woman
2. Place the woman in a left lateral position
3. Ensure that the fetus is viable (estimated fetal weight >800-900 g) & has no obvious lethal congenital abnormalities
4. Perform vaginal examination for cervical dilatation, & to exclude cord prolapse or cord presentation
5. Unless hypertensive or cardiac, give a 500 mL intravenous bolus of Ringer-Lactate
6. Stop oxytocin infusion if labour is induced or augmented
7. If the fetal heart rate shows no improvement:
   • If vaginal delivery is imminent (cervix fully dilated), deliver immediately, by vacuum extraction or forceps if feasible & necessary
   • If vaginal delivery is not imminent, give salbutamol 250 mcg IV over 2 minutes and prepare for immediate caesarean section 
8. Give oxygen by face mask, using equipment to achieve an FiO₂ of 80% only if mother is hypoxic or a long delay to perform a caesarean section
9. Call the neonatology doctor to be present at birth

CORD PROLAPSE

Cord prolapse is associated with preterm labour, high presenting part or malpresentation. It should be looked for where there is sudden onset of variable decelerations on CTG, and after performing artificial rupture of membranes.

If the fetus is alive (cord pulsating or fetal heart heard or detected on ultrasound) and viable (estimated weight >800-900g):

1. Call for help
2. Explain the problem to the woman
3. Perform vaginal examination:

• If the cervix is fully dilated and the woman can push the head or breech to the pelvic floor, deliver immediately, by vacuum or forceps if necessary
• If the cervix is not fully dilated, arrange an urgent caesarean section & proceed as follows:

1. Replace the cord in the vagina, and handle the cord as little as possible
2. With the fingers, push the presenting part off the cord. Do not remove the fingers from the presenting part if the cord is compressed
3. Give a 500 mL intravenous infusion bolus of Ringer-Lactate, unless hypertensive or cardiac (no bolus, 70-100 mL/hour)
4. Give salbutamol 250 mcg IV over 2 minutes
5. Insert an indwelling urinary catheter, at least size 18 F & empty the bladder
6. Rapidly fill the bladder with 400 mL saline, then clamp the catheter
7. Place the woman in a left lateral position with buttock support, or in the knee-elbow position if the presenting part is engaged in the pelvis and compressing the cord
8. Make accurate notes of all that was done, with times
9. Before starting the caesarean section, make sure the baby is still alive
10. At caesarean section, bear in mind the full bladder & remove the catheter clamp as soon as the uterus is ready for incision

If the baby is not alive or non-viable, continue labour in the safest way for the woman, with appropriate analgesia or sedation

Cord presentation

In cord presentation, the umbilical cord can be felt behind intact membranes in front of the presenting part. Unless the cervix is fully dilated & the head is on the pelvic floor, this requires emergency caesarean section. If the membranes rupture while waiting for caesarean section, immediately check for cord prolapse & manage appropriately.

SHOULDER DYSTOCIA

This occurs with large babies (usually >4 kg) when delivery of the head is not followed by delivery of the shoulders. To anticipate shoulder dystocia, be aware of risk factors such as an obese woman, diabetic woman, previous large baby, prolonged labour, and SFH >40 cm. Frequently, shoulder dystocia occurs without any identifiable risk factor.

1. Call for at least 2 assistants to help with delivery
2. Explain the problem to the woman
3. Immediately move the woman to the edge or end of the delivery bed
4. Get the woman to hyperflex her hips with the help of assistants. Her knees should almost touch her shoulders (McRoberts’ position)
5. Apply suprapubic pressure to force the anterior shoulder under the symphysis
6. Hold the head with two hands & deliver, but do not pull on and bend the neck, as this may cause brachial plexus injury
7. If unsuccessful, deliver the posterior arm by finding the posterior shoulder in the vagina & sweeping the arm in front of the chest.  Once the posterior arm is delivered, proceed to deliver the anterior shoulder as above
8. If this fails, attempt to pull down the posterior arm by using a suction tube or urinary catheter bag tube inserted behind the posterior axilla
9. Consider turning the woman to a knee-elbow position and attempting to deliver the posterior arm as above 
10. If the baby is dead, avoid traumatic manoeuvres and await spontaneous delivery. Call for help if delivery is excessively delayed
11. After delivery, carefully inspect the perineum for damage, especially third degree tear
12. Make clear notes about the actions taken, with times

Alternative methods in extreme cases include:

• Rotation of the baby so that the posterior shoulder becomes anterior
• Fracture of one or both clavicles
• Hyperextension of hips with legs over the edge of the bed
• Cephalic replacement using the Zavanelli manoeuvre with salbutamol tocolysis, followed by caesarean section
• Symphysiotomy

POOR PROGRESS IN THE SECOND STAGE

The labour ward midwives should call a doctor: 

• If the woman has not started pushing after 1 hour of full dilatation, or
• If delivery has not occurred after 45 minutes of pushing in a nullipara, or 30 minutes of pushing in a multipara

If the woman is not bearing down after 1 hour of full dilatation:

1. Re-examine to make sure the cervix is fully dilated
2. Rupture the membranes if they are still intact
3. Exclude cephalopelvic disproportion, fetal distress or breech presentation: these will necessitate caesarean section
4. Estimate descent of the head in fifths palpable above the brim, i.e. the portion of head that still needs to descend into the pelvis
5. If the head is on the perineum, ask the woman to push, then assess descent & deliver if appropriate
6. If not for immediate delivery, start oxytocin infusion
7. Continue routine monitoring of the second stage
8. Re-assess after one more hour: if not delivered, caesarean section or assisted vaginal delivery will be required
9. With epidural analgesia, the second stage may be allowed to extend to three hours, provided there is no evidence of disproportion or fetal distress

Failure of the head to descend despite pushing

If delivery has not occurred after 45 minutes of pushing in a nullipara, or 30 minutes in a multipara:

• Perform assisted vaginal delivery if the head is 0/5 or 1/5 palpable above the pelvic brim, with oxytocin infusion if necessary
• Perform caesarean section if the head is 2/5 or more palpable above the pelvic brim