Labour complications

Shoulder dystocia

Baby’s shoulder becomes trapped against the symphysis pubis, preventing progress through the birth canal

Presentation

• Difficulty with birth of face and chin
• Fetal head retracting against perineum (“turtle sign”)
• Failure of the fetal read to restitute
• Failure of shoulder to descend

Risk factors

Maternal

• Increased age
• Obesity
• Prolonged pregnancy
• Short stature
• Hx of Shoulder Dystocia
• Gestational Diabetes
• Overdue
• Abnormal pelvic anatomy

Foetal

• Suspected Macrosomia (baby weight > 4.5kg)
• Protracted active first or second stage of labour
• Anomalies (e.g. Hydrocephalus)
• Conjoined twins

Risks on birthing

• Increased maternal risk of PPH and fourth degree perineal tears;
• Increased risk of fetal injury, especially brachial plexus injuries.

Management

Do each of the following for 30 seconds before progressing to the next

1. McRoberts position is flexion and abduction of the maternal hips, positioning the maternal thighs on her abdomen.
2. Rubin 1 manoeuvre is continuous suprapubic pressure applied in the McRoberts position to improve success rate.
3. Rockin rubin is then adopted in an attempt to deliver the impacted shoulder.
4. The mother is then positioned on all fours (reverse McRoberts) in an attempt to deliver the none impacted shoulder.

Paramedics, as not trained, should not conduct internal maneouvres

Cord prolapse

If the cord is visible at the vaginal opening after the membranes have ruptured. This should be considered in all women at high risk for cord prolapse;

• Malpresentation
• Low birth weight
• Multiple gestation
• Multiparity
• Preterm Labour
• Abnormally long umbilical cord

Can present three ways:

Funic

Umbilical cord lies in front of presenting part

Membranes are intact

Overt prolapse

Cord lies in front of presenting part

Membranes are ruptured

Occult presentation/prolapse

Cord lies trapped beside presenting part rather than below it

Management

• Do NOT touch the cord or push the cord back in
• Position patient appropriately:
  • Place the mother in a knee to chest position (effectively all fours but knees closer to chest); and
  • Transport in the exaggerated sims position to keep fetal presenting part off the cord

Breech

Breech presentation means the baby is lying longitudinally with its bottom and/or feet presenting first to the lower part of the mother’s uterus. (RANZCOG, 2016).

Common in pre-term labour where baby hasn’t rotated/adjusted appropriately in uterine.

Presentations

Frank

Backside is presenting element

Complete

Feet/backside presenting

Footling

Foot/feet presenting

Risk factors

• Nulliparous women
• Previous Breech presentation
• Pre-term delivery
• Multiple pregnancies
• Placenta praevia
• Malformation of uterus or foetus
• Uterine and congenital abnormalities

Management

• Delivery should NOT be attempted unless it is absolutely inevitable
• Delivery of a footling breech should NOT be attempted in the pre-hospital setting
• Don’t attempt to push the baby back in or pull on baby
• Consider Mauriceau Smellie Veit (MSV) maneoeuvre if baby’s head doesn’t deliver spontaneously
• Consider and exclude cord prolapse

Post partum haemorrhage (PPH)

PPH is blood loss of 500mls or greater during or after labour. It can be classified as severe when loss is greater than 1000ml or where haemodynamic instablity is present.

Primary PPH

Occurs within first 24 hours

Secondary PPH

Occurs after 24 hours post labour up to 6 weeks post partum

There is increased maternal risk where a prolonged third stage of labour exists

PPH risk factors

The four T’s :

Tone (70%)

Abnormalities of uterine contraction

Trauma (20%)

Genital tract trauma

Tissue (10%)

Retained pregnancy tissue

Thrombin (1%)

Derranged/abnormal coagulopathy

Management of PPH

1. Fundal massage
2. Fundal massage
3. Breast feeding (releases Oxytocin)
4. Urination

If unsuccessful

1. Bimanual uterine massage and compression
2. Suprapubic compression

If TXA available consider via support paramedic, consider en route RV (positive results from the WOMAN trial)