11.3 Labor, Delivery & Postpartum Management

Labor, Delivery & Postpartum Management

Normal & Abnormal Labor Progress

Labor is defined as progressive cervical effacement and dilation accompanied by regular, painful uterine contractions. Labor is clinically divided into three stages:

• First Stage: Onset of labor to complete cervical dilation (10 cm).
  • Latent Phase: 0 to 6 cm dilation. Characterized by slow cervical change. Prolonged latent phase is defined as >20 hours in nulliparas or >14 hours in multiparas. Management involves rest, hydration, or oxytocin; prolonged latent phase is NOT an indication for C-section.
  • Active Phase: 6 cm to 10 cm dilation. Characterized by rapid cervical dilation (expected rate ≥1.0 cm/hour in nulliparas, ≥1.2 cm/hour in multiparas).
  • Active Phase Protraction: Cervical dilation progression slower than expected (<1.0–1.2 cm/hr) after 6 cm. Managed with amniotomy (artificial rupture of membranes) and oxytocin augmentation.
  • Active Phase Arrest Criteria: Diagnosed when cervical dilation is ≥6 cm with ruptured membranes AND there is no cervical change for ≥4 hours despite adequate uterine contractions (>200 Montevideo units [MMUs] over a 10-minute window measured by intrauterine pressure catheter) OR no cervical change for ≥6 hours of inadequate contractions despite oxytocin administration. Management of active phase arrest requires Cesarean delivery.
• Second Stage: Complete cervical dilation (10 cm) to delivery of the fetus. Prolonged 2nd stage is defined as >3 hours in nulliparas (>4 hours with epidural) or >2 hours in multiparas (>3 hours with epidural).
• Third Stage: Delivery of the fetus to delivery of the placenta. Normal duration is <30 minutes. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of blood, and the uterus becoming firm and globular.

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Intrapartum Fetal Monitoring & Resuscitation

Electronic fetal monitoring (EFM) evaluates fetal oxygenation during labor by analyzing baseline heart rate, variability, accelerations, and decelerations.

• Baseline Fetal Heart Rate (FHR): Normal is 110–160 bpm (bradycardia <110 bpm, tachycardia >160 bpm).
• Fetal Heart Rate Variability: Refers to fluctuations in baseline FHR. Moderate variability (6–25 bpm) is the single most reliable sign of adequate fetal central nervous system oxygenation.
• Deceleration Types:
  • Early Decelerations: Symmetrical, gradual decrease in FHR coincident with uterine contraction (nadir matches peak of contraction). Cause: fetal head compression (vagal stimulation). Benign; requires no intervention.
  • Variable Decelerations: Abrupt decrease in FHR (onset to nadir <30 seconds), dropping ≥15 bpm lasting ≥15 seconds. Cause: umbilical cord compression. Managed with maternal position changes; if recurrent, amnioinfusion (instillation of saline via IUPC) decreases cord compression.
  • Late Decelerations: Symmetrical, gradual decrease in FHR with nadir occurring after the peak of contraction. Cause: uteroplacental insufficiency (fetal hypoxia). Requires immediate intrauterine resuscitation.
• EFM Three-Tier Category System:
  • Category I (Normal): Baseline 110–160 bpm, moderate variability, absence of late/variable decelerations. Highly predictive of normal acid-base status.
  • Category II (Indeterminate): Tracings not categorized as I or III (e.g., minimal variability, absent accelerations, recurrent variable decelerations). Requires continued surveillance and intrauterine resuscitation measures.
  • Category III (Abnormal): Absent baseline variability accompanied by recurrent late decelerations, recurrent variable decelerations, or bradycardia; OR a sinusoidal pattern. Predictive of abnormal fetal acid-base status (fetal acidemia). Requires immediate intrauterine resuscitation and urgent Cesarean delivery if unresolved.
• Intrauterine Resuscitation Protocol:
  1. Position patient in left lateral tilt (relieves aortocaval compression by gravid uterus)
  2. Administer IV fluid bolus (improves placental perfusion)
  3. Administer supplemental oxygen via non-rebreather mask
  4. Discontinue oxytocin or uterine stimulants immediately
  5. Administer a tocolytic agent (IV terbutaline) if uterine tachysystole (>5 contractions in 10 minutes) is present

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Obstetric Emergencies

Shoulder Dystocia

Impaction of the anterior fetal shoulder behind the maternal pubic symphysis following delivery of the fetal head. Signs: "Turtle sign" (retraction of fetal head against perineum). High risk of brachial plexus injury (Erb-Duchenne palsy C5-C6), clavicular fracture, and fetal hypoxia.

• Management (HELPERR Protocol):
  1. Call for emergency assistance
  2. McRoberts Maneuver (First-line): Hyperflexion and abduction of maternal hips onto the abdomen (flattens sacral promontory and increases anteroposterior pelvic diameter).
  3. Suprapubic Pressure (First-line): Applied dislodging the anterior shoulder laterally behind the pubic symphysis. Applied downward and laterally.
  4. Internal maneuvers: Rubin II / Woods screw maneuver (rotation of fetal shoulders), delivery of posterior arm.
  5. CRITICAL: Fundal pressure is strictly CONTRAINDICATED, as it worsens shoulder impaction and increases uterine rupture risk.

Postpartum Hemorrhage (PPH)

Defined as cumulative blood loss ≥1,000 mL OR blood loss accompanied by signs/symptoms of hypovolemia within 24 hours of delivery. The leading cause of maternal mortality worldwide. Organised by the "4 Ts":

1. Tone (Uterine Atony - 70-80% of cases): Soft, boggy, poorly contracted uterus extending above umbilicus.
2. Trauma (15%): Vaginal, cervical, or perineal lacerations, uterine rupture.
3. Tissue (10%): Retained placental fragments or placenta accreta.
4. Thrombin (1%): Coagulopathy (DIC, von Willebrand disease).

Uterine Rupture

Complete disruption of all uterine wall layers. Most common in patients with a prior Cesarean delivery undergoing trial of labor after C-section (TOLAC). Classic presentation: sudden severe abdominal pain, loss of fetal station (regression of presenting part), vaginal bleeding, and abrupt fetal bradycardia or Category III tracing. Requires immediate emergency laparotomy, fetal delivery, and uterine repair or hysterectomy.

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Postpartum Care & Complications

• Postpartum Endometritis: Polymicrobial infection of the decidua/myometrium (anaerobes, GNRs, streptococci). Presentation: fever (>38.0°C / 100.4°F after first 24h postpartum), uterine tenderness, purulent foul-smelling lochia, and leukocytosis. Cesarean delivery is the single greatest risk factor (10- to 30-fold increased risk compared to vaginal delivery). First-line antibiotic regimen: Intravenous Clindamycin plus Gentamicin (continued until afebrile for 24 hours).
• Postpartum Mood Disorders:
  • Postpartum Blues: Affects up to 80% of mothers. Onset days 2–3 postpartum, peaks day 5, resolves spontaneously within 14 days. Symptoms: mild tearfulness, fatigue, irritability. Management: reassurance and supportive care.
  • Postpartum Depression: Onset within 12 months postpartum (typically 1–3 months), lasting >2 weeks. Symptoms: depressed mood, anhedonia, sleep disturbance, feelings of worthlessness, impaired bonding with infant. Management: psychotherapy plus SSRIs (Sertraline is preferred in breastfeeding mothers).
  • Postpartum Psychosis: Medical emergency occurring in 0.1-0.2% of births. Onset within days to 2 weeks postpartum. Symptoms: visual/auditory hallucinations, delusions (often involving infant harm), severe agitation. Requires immediate inpatient psychiatric hospitalization for mother and infant safety.
• Lactational Complications:
  • Breast Engorgement: Bilateral, symmetric breast swelling, fullness, warmth, and tenderness occurring 2-4 days postpartum. No systemic fever. Treatment: frequent breastfeeding/pumping, cold compresses.
  • Lactational Mastitis: Unilateral wedge-shaped painful erythema, edema, and induration accompanied by fever (>38.3°C / 101°F), chills, and malaise. Most common pathogen: Staphylococcus aureus. Treatment: Oral Dicloxacillin or Cephalexin for 10-14 days. CONTINUE breastfeeding or pumping from affected breast to prevent milk stasis and abscess formation.

                         [ Cumulative Postpartum Blood Loss ≥1,000 mL ]
                                     (or Signs of Hypovolemia)
                                                 |
       +-----------------------------------------+-----------------------------------------+
       |                                                                                   |
[ Initial Resuscitation & Assessment ]                                     [ Palpate Uterine Fundus ]
 - Call for help / PPH protocol team                                                       |
 - Two large-bore IVs (16-18 gauge)                                       +----------------+----------------+
 - IV crystalloid bolus + type & crossmatch blood                         |                                 |
 - Administer Tranexamic Acid (TXA 1g IV)                         [ Soft, Boggy Uterus ]          [ Firm, Well-Contracted ]
                                                                          |                                 |
                                                                  (Uterine Atony)                [ Evaluate Other 4 Ts ]
                                                                          |                                 |- Lacerations (Trauma)
                                                                          v                                 |- Retained Placenta (Tissue)
                                                              [ Bimanual Uterine Massage ]                  |- Coagulopathy (Thrombin)
                                                                          |
                                                              [ Oxytocin IV Infusion ]
                                                                (1st-Line Uterotonic)
                                                                          |
                                                              +-----------+----------+
                                                              | Still Bleeding?      |
                                                              +-----------+----------+
                                                                          |
                                             +----------------------------+----------------------------+
                                             |                                                         |
                                [ Hypertension Present? ]                                 [ Severe Asthma Present? ]
                                             |                                                         |
                       +---------------------+---------------------+             +---------------------+--------------------+
                       | Yes                 | No                  |             | Yes                 | No                 |
                       v                     v                     v             v                     v                    v
                [ Avoid Methergine ]  [ IV/IM Methergine ]  [ Avoid Hemabate ]   [ Avoid Hemabate ]   [ IM Hemabate ]    [ Sublingual/Rectal ]
                (Give Hemabate or      (0.2 mg IM q2-4h)    (Give Methergine or  (Give Methergine or  (0.25 mg IM q15-90m)  [ Misoprostol ]
                 Misoprostol)                                Misoprostol)         Misoprostol)                             (800-1,000 mcg)
                                                                          |
                                                              +-----------+----------+
                                                              | Persistent Bleeding? |
                                                              +-----------+----------+
                                                                          |
                                                                          v
                                                         [ Intrauterine Balloon Tamponade ]
                                                          (Bakri Balloon / Uterine Packing)
                                                                          |
                                                                          v
                                                         [ Surgical Intervention ]
                                                          (B-Lynch Suture, Uterine Artery
                                                           Embolization, or Hysterectomy)