7.3 Labor, Intrapartum Management, & Postpartum Complications/Hemorrhage

Labor, Intrapartum Management, & Postpartum Complications

Intrapartum care demands precise clinical monitoring of labor progression, fetal well-being, and rapid response to obstetric emergencies. Postpartum management focuses on preventing and treating postpartum hemorrhage (PPH) and puerperal infections in line with SOGC guidelines.

---

Normal Labor: Stages & Cardinal Movements

Labor is defined as regular, painful uterine contractions resulting in progressive cervical effacement and dilation.

The Three Stages of Labor

1. First Stage: Onset of labor to full cervical dilation (10 cm).
   • Latent Phase: Cervical dilation from 0 to 5 cm. Characterized by gradual cervical effacement.
   • Active Phase: Cervical dilation from 6 to 10 cm. Normal progress is ≥1 cm/hour in nulliparas and ≥1.2–1.5 cm/hour in multiparas.
2. Second Stage: Full cervical dilation (10 cm) to delivery of the neonate.
   • Duration limits (SOGC): Nulliparous up to 3 hours (4 hours with epidural); Multiparous up to 2 hours (3 hours with epidural).
3. Third Stage: Delivery of the neonate to delivery of the placenta. Normal duration is <30 minutes.

Cardinal Movements of Labor

As the fetus navigates the maternal birth canal, it undergoes seven classic cardinal movements: Engagement → Descent → Flexion → Internal Rotation → Extension → External Rotation (Restitution) → Expulsion.

---

Assessment of Fetal Well-Being (SOGC EFM Guidelines)

Intrapartum electronic fetal monitoring (EFM) evaluates fetal oxygenation by analyzing baseline fetal heart rate (FHR), variability, accelerations, and decelerations.

Fetal Heart Rate Trace Classification

Deceleration Types & Etiologies

• Early Decelerations: Symmetrical, gradual decrease matching contraction peak. Cause: Head compression (benign vagal response).
• Variable Decelerations: Abrupt drop in FHR (<30 sec to nadir). Cause: Umbilical cord compression.
• Late Decelerations: Symmetrical, gradual decrease starting after contraction peak and returning after contraction ends. Cause: Uteroplacental insufficiency (fetal hypoxia).
• Sinusoidal Pattern: Smooth, wave-like FHR baseline (frequency 3–5 cycles/min). Cause: Severe fetal anemia (Rh isoimmunization, fetomaternal hemorrhage, ruptured vasa previa).

Intrapartum Resuscitation for Category II/III Traces

1. Reposition patient to left lateral tilt (relieves inferior vena cava compression).
2. Administer IV fluid bolus (500–1000 mL Normal Saline or Ringer's Lactate).
3. Discontinue oxytocin infusion immediately.
4. Administer supplemental oxygen (8–10 L/min via non-rebreather mask).
5. Perform vaginal exam to rule out cord prolapse or rapid crowning.
6. If trace remains Category III despite resuscitation: Expedite operative delivery (Vacuum, Forceps, or Emergency Cesarean Section).

---

Intrapartum Obstetric Emergencies

Shoulder Dystocia

Occurs when the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after head delivery. Diagnostic sign: Turtle sign (retraction of fetal head against perineum).

• ALARM / HELPERR Management Protocol:
  1. Call for Help: Summon obstetrics, pediatrics, and anesthesia.
  2. Lift/Hyperflex Legs (McRoberts Maneuver): Hyperflex maternal thighs against abdomen (flattens sacral promontory and rotates pubic symphysis anteriorly).
  3. Suprapubic Pressure: Apply firm downward pressure above pubic bone to dislodge anterior shoulder. Fundal pressure is strictly contraindicated!
  4. Evaluate for Episiotomy: To facilitate internal maneuvers.
  5. Internal Rotational Maneuvers: Rubin II maneuver or Woods Screw maneuver.
  6. Remove Posterior Arm: Reach into vagina and deliver posterior arm across chest.
  7. Zavanelli Maneuver: Push fetal head back into uterus and proceed to emergency C-section (last resort).

Umbilical Cord Prolapse

The umbilical cord slips past the presenting part into the vagina, resulting in cord compression and severe fetal bradycardia.

• Immediate Management:
  • Place gloved hand in vagina and manually elevate the presenting part off the cord.
  • Position patient in knee-chest position or steep Trendelenburg.
  • Keep hand in place elevating the presenting part while transferring immediately to the operating room for Stat Emergency Cesarean Section.

---

Postpartum Hemorrhage (PPH) & SOGC Guidelines

Postpartum Hemorrhage is a major leading cause of maternal mortality.

Definitions

• Primary PPH: Cumulative blood loss ≥500 mL after vaginal delivery OR ≥1000 mL after cesarean delivery (or any bleeding accompanied by signs of hypovolemia) occurring within 24 hours of birth.
• Secondary PPH: Excessive bleeding occurring between 24 hours and 12 weeks postpartum (most commonly due to retained placental fragments or endometritis).

Active Management of the Third Stage of Labor (AMTSL)

SOGC strongly recommends AMTSL for ALL deliveries to reduce PPH risk by up to 60%:

1. Administer Oxytocin 10 IU IM (or 10 IU IV infusion) immediately after delivery of the anterior shoulder or neonate.
2. Controlled cord traction with counter-traction on the uterine fundus.
3. Uterine massage after placental delivery.

Etiology: The 4 Ts Framework

Uterotonic Pharmacotherapy Protocol

1. Oxytocin: First-line. 10 IU IM OR 20–40 IU in 1000 mL IV infusion. (Avoid IV push due to hypotension/arrhythmias).
2. Tranexamic Acid (TXA): Give 1 g IV over 10 minutes within 3 hours of birth. Repeat 1 g IV at 30 minutes if bleeding continues.
3. Ergometrine (Methylergonovine): 0.2 mg IM/IV q2-4h. Contraindicated in Hypertension / Preeclampsia (causes severe vasoconstrictive crisis).
4. Carboprost (Hemabate / PGF2α): 0.25 mg IM q15-90min (max 8 doses). Contraindicated in Asthma (causes severe bronchospasm).
5. Misoprostol (PGE1): 800–1000 mcg sublingually or rectally.

Refractory PPH Management

If uterotonics and massage fail: Insert Bakri Intrauterine Balloon Tamponade (inflated with 300–500 mL sterile saline) → Surgical options: B-Lynch uterine compression sutures, uterine/internal iliac artery embolization, or emergency peripartum hysterectomy.

---

Postpartum Infections & Complications

• Postpartum Endometritis: Infection of the endometrial lining, most common post-cesarean delivery. Presentation: Fever (≥38.0°C), purulent foul-smelling lochia, uterine tenderness, leukocytosis. Treatment: IV Clindamycin (900 mg q8h) + IV Gentamicin (5 mg/kg daily) until afebrile for 24 hours.
• Lactational Mastitis: Regional breast infection (most commonly Staphylococcus aureus). Presentation: Unilateral breast erythema, wedge-shaped induration, high fever, flu-like symptoms. Treatment: Continue breastfeeding/pumping (prevents abscess) + oral Cloxacillin 500 mg PO QID or Cephalexin 500 mg PO QID for 10–14 days.

---

SOGC Clinical Practice Pearls & Exam Traps

⚠️ EXAM TRAP: Remember drug contraindications in PPH:

• Ergometrine is CONTRAINDICATED in Hypertension/Preeclampsia.
• Carboprost (Hemabate) is CONTRAINDICATED in Asthma.

🩺 CLINICAL SCENARIO: A 28-year-old multipara delivers a 4.3 kg neonate vaginally. 15 minutes post-delivery, she has profuse vaginal bleeding amounting to 800 mL. Palpation reveals a soft, boggy uterus located 3 cm above the umbilicus. What is the immediate step-by-step management?

1. Initiate continuous bimanual uterine massage.
2. Administer Oxytocin 20–40 IU in 1L NS IV infusion and Tranexamic Acid 1 g IV.
3. If bleeding persists and BP is normal, administer Ergometrine 0.2 mg IM.
4. Inspect birth canal for trauma and perform manual exploration for retained tissue.