Intrapartum fetal emergencies
Section snippets
Labour
Traditionally, labour is divided into three stages. The first stage includes the slow, latent stage, when the cervix undergoes shortening (effacement) and opening before more rapid dilatation (the active phase) at >3 cm. The second stage is from full dilatation (nominally 10 cm) until delivery of the child. The third stage is concerned with delivery of the placenta.
Partographs chart progress (cervical dilatation and head descent), fetal and maternal observations and any interventions. The
Shoulder dystocia
Shoulder dystocia is associated with significant morbidity and mortality. The term describes any difficulty with the delivery of the fetal shoulders after the head has been delivered. Differing descriptions and terminology make it difficult to accurately assess the true incidence of this frightening obstetric emergency, although the reported range is 0.2–2% of vaginal cephalic deliveries.3 A standardised description, proposed by Spong, defines the problem as a prolonged head-to-body delivery
Cord prolapse
Cord prolapse occurs when the umbilical cord descends below the presenting part of the fetus after the membranes have ruptured. This can occur at any time during the antenatal period, intrapartum or at the time of delivery. It becomes an emergency when the presenting part compresses the umbilical cord, which in turn affects fetal oxygenation.
Cord prolapse occurs in 0.2–0.4% of all births24, 25 and risk factors include prematurity, birthweight <2.5 kg, non-cephalic presentations, multi-fetal
Uterine rupture
Uterine rupture is one of the most dangerous obstetric emergencies, causing acute compromise for both mother and fetus. Over the last few decades, the aetiology of this catastrophic event has changed, with previous caesarean section now the leading cause.37
It is difficult to assess the incidence of this condition accurately, as there are huge global variations. The effects on morbidity and mortality also vary geographically, with rupture causing up to 16% of maternal deaths in one African
Placental abruption
Placental abruption is a serious complication of pregnancy, defined as premature separation of a normally sited placenta. It occurs in approximately 1% of all pregnancies and is associated with a high perinatal mortality rate of up to 119 per 1000 births complicated by abruption.42 The incidence is higher in women with hypertensive disorders, preterm premature rupture of membranes, tobacco and cocaine use, multiple pregnancies, hydramnios, trauma and thrombophilias. A history of previous
Breech delivery
For years, although the view held by some obstetricians—that vaginal breech delivery had unacceptably high risks compared to caesarean section—was supported by observational studies, many remained unconvinced. A large multi-centre, randomised controlled trial designed to address this issue found that elective operative delivery of a diagnosed breech at term was safer than the vaginal route, reducing the risk of serious outcomes by 67%.51
In a normal breech delivery, the fetus is ‘assisted’,
Conclusion
As a result of their very nature, intrapartum emergencies do not easily lend themselves to critical assessment using randomised trials. Ethical considerations surrounding consent and obvious recruitment issues make such research difficult to complete. Therefore, optimal management will continue to be based on observational studies and expert consensus.
Labour will always be a potentially hazardous journey for the fetus but with improved understanding of the potential dangers, combined with
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Cited by (8)
Chapter 32 - Placental Correlates of Unanticipated Fetal Death
2018, Diagnostic Gynecologic and Obstetric PathologyA model for educational simulation of the effect of oxytocin on uterine contractions
2013, Medical Engineering and PhysicsCitation Excerpt :Simulation is being increasingly used as an educational tool in acute care medicine. It provides a risk free and controllable environment for training healthcare providers in the technical and nontechnical skills required to handle rare and life-threatening situations [1,2]. Labor and delivery carry with them some risk to the fetus, and educational simulation has been shown to improve outcomes in this area [3–7].
An intrauterine pressure generator for educational simulation of labour and delivery
2010, Medical Engineering and PhysicsUterine Rupture: A Rare Event But Terrible to Know How to Face
2023, Practical Guide to Simulation in Delivery Room EmergenciesShoulder dystocia an obstetrical emergency
2011, Acta Medica Portuguesa