3.1 Obstetric Intrapartum Emergencies
Key Takeaways
- Shoulder dystocia requires immediate team response and rapid maneuvers, commonly beginning with McRoberts and suprapubic pressure; never use fundal pressure, and do not let a mnemonic delay an indicated maneuver.
- For overt cord prolapse, call for help, elevate the presenting part, position to reduce compression, stop uterotonics, and expedite birth—usually cesarean unless vaginal birth can be completed faster.
- The most consistent sign of uterine rupture is a sudden fetal heart-rate abnormality; pain, bleeding, loss of station, and shock may occur but are not universally present.
- For maternal cardiac arrest with the fundus at or above the umbilicus, perform high-quality supine CPR with manual left uterine displacement and prepare immediately for resuscitative delivery, aiming to complete by 5 minutes if there is no ROSC.
3.1 Obstetric Intrapartum Emergencies
Intrapartum obstetric emergencies represent acute, unpredictable events during labor and delivery that threaten the life of the pregnant patient, the fetus, or both. Successful clinical outcomes depend upon rapid nursing assessment, immediate mobilization of an interprofessional team, and rigid adherence to evidence-based intervention protocols. The inpatient obstetric nurse must remain highly proficient in managing shoulder dystocia, umbilical cord prolapse, uterine rupture, and amniotic fluid embolism (AFE).
Shoulder Dystocia: Recognition & The HELPERR Protocol
Shoulder dystocia occurs when the fetal head delivers vaginally, but the anterior fetal shoulder becomes impacted behind the maternal symphysis pubis (or less commonly, the posterior shoulder becomes impacted on the sacral promontory). It is a true emergency because cord compression between the fetal body and the maternal bony pelvis rapidly leads to fetal hypoxia and acidemia.
Clinical Warning Signs & Initial Actions
- The "Turtle Sign": Retraction of the delivered fetal head back against the maternal perineum, resembling a turtle withdrawing into its shell.
- Failure of restitution: The fetal head fails to rotate naturally after delivery.
- Immediate First Steps:
- Call for Help: Announce shoulder dystocia clearly to labor room staff. Mobilize the obstetrician, neonatal resuscitation team (NICU/pediatrician), extra labor nurses, and anesthesia.
- Note the Time: Assign a dedicated staff member to track elapsed time from head delivery to body delivery.
- Stop Maternal Pushing: Instruct the patient to stop pushing immediately to avoid further impaction of the anterior shoulder.
- NO Fundal Pressure: NEVER apply fundal pressure! Fundal pressure worsens shoulder impaction, increases the risk of uterine rupture, and dramatically elevates the rate of permanent brachial plexus injury.
The HELPERR Management Mnemonic
| Letter | Action | Clinical Technique & Nursing Rationale |
|---|---|---|
| H | Help | Call for extra assistance, obstetric provider, neonatology, anesthesia, and extra nursing staff. |
| E | Evaluate for Episiotomy | Episiotomy does not relieve the bony impaction of shoulder dystocia, but it provides space for the provider's hands to execute internal rotational maneuvers. |
| L | Legs (McRoberts Maneuver) | Hyperflex the maternal legs back against the abdomen. This flattens the lumbosacral angle, rotates the symphysis pubis cephalad, and increases the anteroposterior diameter of the pelvic outlet. Success rate is ~40–50% as a primary maneuver. |
| P | Pressure (Suprapubic) | Apply downward and lateral pressure over the maternal lower abdomen over the anterior fetal shoulder (behind the symphysis pubis) toward the fetal chest to dislodge the anterior shoulder. |
| E | Enter (Internal Rotational) | Provider inserts fingers into the vagina to execute internal maneuvers: Rubin II (pressure on posterior aspect of anterior shoulder) or Woods Screw maneuver (rotating posterior shoulder 180 degrees). |
| R | Remove Posterior Arm | Provider reaches into vagina, sweeps the posterior arm across the fetal chest, and delivers the posterior arm, reducing the shoulder width by the diameter of the arm. |
| R | Roll the Patient (Gaskin) | Position the patient onto all fours (hands and knees). This increases pelvic dimensions and utilizes gravity to dislodge the impacted shoulder. |
Rescue & Secondary Maneuvers
If standard maneuvers fail, secondary interventions include intentional fracture of the fetal clavicle, Zavanelli maneuver (replacing the fetal head into the vagina followed by STAT cesarean delivery), or symphysiotomy (surgical division of symphysis pubis cartilage).
Maternal and Neonatal Complications
- Neonatal: Brachial plexus injury (Erb's palsy involving nerve roots C5–C6 or Klumpke's palsy involving C8–T1), clavicular or humeral fracture, subgaleal hematoma, birth asphyxia, and hypoxic-ischemic encephalopathy (HIE).
- Maternal: Severe 3rd or 4th-degree perineal lacerations, extension of episiotomy, bladder injury, and postpartum hemorrhage (PPH) secondary to uterine atony or lacerations.
Umbilical Cord Prolapse
Umbilical cord prolapse occurs when the umbilical cord drops ahead of or alongside the fetal presenting part into the lower uterine segment, cervix, or vagina. Compression of the cord between the presenting part and the maternal pelvis restricts fetal umbilical blood flow, resulting in severe fetal bradycardia and acute asphyxia.
Classification & Risk Factors
- Overt Prolapse: The umbilical cord protrudes through the cervix into the vagina or past the introitus; visible or directly palpable on exam.
- Occult Prolapse: The cord lies alongside the presenting part inside the cervix; not visible or directly palpable, but heralded by recurrent severe variable decelerations or prolonged bradycardia.
- Primary Risk Factors:
- Premature rupture of membranes (PROM) or artificial rupture of membranes (AROM) when the presenting part is unengaged (high station: -2 or -3).
- Malpresentation (breech lie, footling breech, transverse lie).
- Polyhydramnios (rapid outflow of fluid carries cord downward).
- Multiple gestation (second twin after delivery of first twin).
- Small for gestational age (SGA) or prematurity.
Emergency Nursing Interventions
- Manual Elevation of Presenting Part: Immediately insert a sterile gloved hand into the vagina and push the fetal presenting part UP and OFF the umbilical cord. Maintain upward pressure until the presenting part no longer compresses the cord or birth occurs; do not remove the hand during transfer.
- Maternal Positioning: Shift the patient into Trendelenburg position or knee-chest position (or modified Sims position with elevated hips) to utilize gravity to shift the fetal weight off the cord.
- Maternal Support: Give oxygen for maternal hypoxemia and maintain IV access; use fluids according to maternal hemodynamics.
- Cord Care: If the cord is exposed outside the vagina, wrap it gently with warm, sterile saline-soaked gauze. DO NOT attempt to push the cord back into the cervix or vagina, as mechanical manipulation triggers severe vasospasm.
- Medication & Delivery: Discontinue oxytocin immediately; administer terbutaline 0.25 mg SQ if hypertonus exacerbates compression; expedite birth. Cesarean is usual when vaginal birth is not imminent, but a fully dilated patient may be delivered vaginally if that is clearly faster and feasible.
Uterine Rupture
Uterine rupture is a catastrophic event characterized by a full-thickness tear of all uterine wall layers (myometrium and serosa), leading to expulsion of fetal parts, placenta, or blood into the maternal peritoneal cavity.
Risk Factors
- Prior cesarean delivery—especially a classic vertical uterine incision (highest risk: 4–9%).
- Prior transfundal uterine surgery (e.g., extensive myomectomy entering endometrial cavity).
- Hyperstimulation from oxytocin or prostaglandin induction agents.
- High parity, grand multiparity, or uterine trauma.
Clinical Presentation
A sudden fetal heart-rate abnormality—often prolonged deceleration or bradycardia—is the most consistent sign. Possible findings include new pain, bleeding, loss of station, change in uterine contour, cessation of previously effective contractions, maternal tachycardia or hypotension, and hematuria. Epidural analgesia or incomplete rupture may blunt pain, so absence of a classic “tearing” description does not exclude rupture.
Management
- Immediate emergency laparotomy and STAT cesarean delivery.
- Massive transfusion protocol (MTP) initiation with packed red blood cells (PRBCs) and fresh frozen plasma (FFP).
- Surgical repair of uterine defect or emergency hysterectomy if bleeding cannot be controlled.
Amniotic Fluid Embolism (AFE) / Anaphylactoid Syndrome of Pregnancy
Amniotic fluid embolism (AFE) is a rare, unpredictable syndrome of abrupt cardiorespiratory collapse and coagulopathy during labor, birth, or the early postpartum period. Its pathophysiology is incompletely understood; fetal material in maternal circulation does not by itself explain or diagnose the syndrome.
Clinical Presentation Triad
- Sudden Hypoxia & Respiratory Collapse: Acute dyspnea, cyanosis, pulmonary edema, respiratory arrest.
- Hemodynamic Collapse: Severe hypotension, ventricular dysrhythmias, cardiogenic shock, cardiac arrest.
- Disseminated Intravascular Coagulation (DIC): Profuse hemorrhage from IV sites, incision lines, vagina, and mucous membranes.
Immediate Resuscitation Nursing Protocol
Activate the maternal cardiac-arrest and massive-transfusion response, begin high-quality CPR, manage the airway, and treat reversible causes. Keep the patient supine for effective compressions while a team member performs manual left uterine displacement when the fundus is at or above the umbilicus. Use standard defibrillation doses and remove fetal monitors.
Preparation for resuscitative delivery begins when arrest is recognized. If the fundus is at or above the umbilicus and return of spontaneous circulation is not achieved, perform delivery at the arrest location with the goal of completing it by 5 minutes. Its primary purpose is improving maternal resuscitation by relieving aortocaval compression. Current guidance does not recommend atropine in the absence of bradycardia for suspected AFE.
During a labor delivery, the fetal head delivers, but then retracts tightly against the perineum (turtle sign). The nurse recognizes a shoulder dystocia. What is the immediate first-line nursing action following the call for emergency assistance?
A laboring patient at 39 weeks gestation with unengaged fetal head (-2 station) experiences spontaneous rupture of membranes. The nurse performs a vaginal exam and palpates a pulsating loop of umbilical cord in the vagina. What is the priority nursing intervention?
A patient attempting a trial of labor after cesarean (TOLAC) suddenly reports sharp, tearing lower abdominal pain and shoulder tip distress. Electronic fetal monitoring reveals a sudden severe prolonged fetal bradycardia, and vaginal examination shows that the fetal presenting part has receded from +1 station to -3 station. What intrapartum emergency is occurring?