Intrapartum fetal emergencies

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Summary

Labour is one of the shortest yet most hazardous journeys humans take during their lifetime. Currently, our methods of identifying those fetuses at particular risk of compromise during labour are limited. Antepartum tests of placental reserve give little information about an individual fetus's ability to cope with passage through the birth canal and some might already have received a silent insult earlier in the pregnancy that places them at increased risk. In addition to the normal processes of labour, other, more unpredictable factors can act to place the fetus in acute danger.

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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