19.7 Obstetrical Emergencies

Fetal Distress

Fetal distress is most commonly diagnosed using fetal monitor tracing. The three-tiered categories of FHR tracings guide the nurse and health-care provider to determine the status of the fetus (ACOG, 2009a; Hernandez Engelhart et al., 2023). See definitions of these categories in Chapter 16 Electronic Fetal and Uterine Contraction Monitoring. Category II tracings suggesting difficulty in determining fetal well-being should be monitored to determine if interventions, such as giving an intravenous fluid bolus or repositioning the laboring person, will resolve the issue. After multiple interventions, if the FHR remains Category II, the nurse will continue to monitor the labor progress and the FHR pattern and communicate with the health-care provider. When the nurse interprets the FHR pattern as Category III, the health-care provider is notified. Once the health-care provider confirms the Category III tracing, delivery is expected within 30 minutes (Lyndon & Wisner, 2021). The nurse also contacts the neonatal team to be present at the birth due to the potential complications for the fetus. The nurse keeps the laboring person and family up to date on what interventions are being done and acts as support during this stressful period.

Shoulder Dystocia

The impaction of the fetal shoulder into the symphysis pubis or sacral promontory, preventing the delivery of the fetus is called shoulder dystocia. It occurs in less than 3 percent of births (ACOG, 2017a). The health-care provider attempts to deliver the anterior shoulder, but the shoulder lodges under the pubic bone and is not delivered. Figure 19.16 illustrates shoulder dystocia. Predicting shoulder dystocia is not always successful. Risk factors for shoulder dystocia are obesity, excessive weight gain, multiparity, increased birth weight, and diabetes (Hill & Cohen, 2016). However, 50 percent of shoulder dystocia occurs in normal-weight fetuses and persons who do not have diabetes; therefore, the nurse should always be prepared for shoulder dystocia. A good predictor of shoulder dystocia is a past shoulder dystocia.

Figure 19.16 Shoulder Dystocia Shoulder dystocia occurs when the anterior shoulder is stuck behind the pubic bone. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Complications of shoulder dystocia include increased risk of postpartum hemorrhage and perineal lacerations. Fetal complications include brachial plexus injuries and fractures of the clavicle and humerus (ACOG, 2017a). These injuries usually resolve; however, shoulder dystocia can cause fetal hypoxia and death.

Management of shoulder dystocia should be systematic and rapid. The nurse and health-care providers must act quickly to resolve the dystocia. The nurse positions the person to help the provider perform maneuvers. The first maneuver is McRoberts maneuver, which is the process of flexing the laboring person’s legs until the thighs touch the abdomen. Posterolateral suprapubic pressure is then provided in hopes of dislodging the shoulder from underneath the pubic bone. The nurse will need a stool to get above the person and give downward, lateral pressure with one or both hands toward the fetal-facing side. See Figure 19.17 for a demonstration of posterolateral suprapubic pressure. The nurse does not give fundal pressure because that impacts the shoulder further. If this maneuver is not successful, the health-care provider will attempt to deliver the posterior arm or attempt to turn the shoulders. The nurse is also prepared to turn the person to hands-and-knees position (Gaskin maneuver) if previous maneuvers are not successful. See Table 19.12 for a mnemonic, HELPERR, to remember the maneuvers for a shoulder dystocia.

Figure 19.17 Posterolateral Suprapubic Pressure Applying posterolateral suprapubic pressure in the event of shoulder dystocia can aid in delivery. (credit: “Suprapubic-pressureforSD” by Henry Lerner/Wikimedia Commons, CC BY 4.0)

Prolapsed Cord

When the umbilical cord lies beside or in front of the fetal presenting part, it is called a prolapsed cord. This is an emergency because oxygen is unable to reach the fetus due to cord occlusion. Figure 19.18 demonstrates a prolapsed cord. A prolapsed cord is usually diagnosed after rupture of the amniotic membranes, either spontaneously or artificially. The fetal monitor tracing will usually show a prolonged deceleration. The nurse suspects a prolapsed cord and does a vaginal exam. Many times, the cord with pulsation is felt in the vagina. At other times it cannot be palpated, but the assumption is made because of the prolonged deceleration. The nurse will lift the presenting part off the cord to allow for perfusion to the fetus. The nurse calls for assistance while keeping the presenting part elevated. An emergency cesarean birth will be performed, and the nurse’s hand will remain lifting the presenting part until the fetus is delivered.

Figure 19.18 Prolapsed Cord The cord is prolapsing in front of the fetal head, causing cord compression. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Uterine Rupture

A uterine rupture is defined as a tearing or an opening in the muscle of the uterus. Figure 19.19 illustrates a uterine rupture. It is seen more commonly in persons with a previous cesarean birth. Most ruptures occur during labor, but some occur during pregnancy. Uterine rupture is an emergency for the fetus and the pregnant person. The pregnant person can hemorrhage quickly, and the fetus can be deprived of oxygen. Time is important in this emergency. The nurse is aware that the fetus must be born quickly, usually via cesarean, and that the uterus must be repaired before the pregnant person has lost an excessive amount of blood.

Figure 19.19 Uterine Rupture The uterus is ruptured, and the head of the fetus is protruding into the abdominal cavity. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Risk factors for uterine rupture are a history of a cesarean or other uterine surgery, uterine trauma, polyhydramnios, and prolonged labor. If a fetal monitor is in place, the symptoms of uterine rupture are that the FHR no longer traces and contractions are not present. If the patient does not have an epidural, they may notice a lack of pain. Other signs could be late decelerations or prolonged decelerations and severe abdominal pain in the pregnant person. Vaginal bleeding may or may not be seen (Lumala & Atwijukire, 2021).

The nurse caring for a pregnant person attempting a VBAC is aware of the higher risk for uterine rupture. The pregnant person attempting a VBAC is on continuous monitoring to screen for fetal distress because this is sometimes the first sign of uterine rupture. When uterine rupture is suspected, the nurse quickly calls for assistance and prepares the person for an emergency cesarean birth. The nurse is prepared to order blood products because risk for postpartum hemorrhage is high. The perinatal team will be in the operating room to care for a depressed newborn.

Anaphylactoid Syndrome of Pregnancy

An anaphylactic reaction to amniotic fluid entering the respiratory system is anaphylactoid syndrome of pregnancy (ASP), also known as amniotic fluid embolus. The incidence of ASP is anywhere from 1 in 80,000 to 1 in 20,000 pregnancies; the incidence has a large range because the clinical diagnosis of ASP is usually done retrospectively or during autopsy (Barnhart & Rosenbaum, 2019).

For ASP to occur, an opening between the amniotic sac and the pregnant person’s venous system must exist. This happens at the time of rupture of membranes or at other times during labor and birth. Risk factors include:

• multiparity
• tachysystole
• advanced maternal age
• uterotonics
• cesarean birth
• uterine rupture
• uterine trauma
• premature separation of the placenta
• IUFD

(Fox et al., 2019).

Amniotic debris, vernix, hair, and other tissue enters the cardiopulmonary system, leading to shock similar to sepsis or anaphylaxis (Fox et al., 2019). Symptoms are respiratory distress, cyanosis, hypotension, and seizure. Treatment is to support the person’s respiratory and cardiovascular systems. Many persons go into cardiac arrest and require intubation and ventilator support. The majority of persons experiencing ASP will have disseminated intravascular coagulation. The mortality rate associated with ASP is 60 to 80 percent (Fox et al., 2019). Those who survive can have neurologic damage leading to seizures, confusion, or coma (Kaur et al., 2016). The role of the nurse is to assist the health-care provider, support the laboring person, and keep the family up to date on the interventions being performed. The nurse also anticipates the need for escalation of care to the intensive care unit for the laboring person and the NICU for the newborn.

Disseminated Intravascular Coagulation

The condition associated with the coagulation cascade in which the body releases all of its clotting and anti-clotting factors, leading to massive hemorrhage and organ failure is disseminated intravascular coagulation (DIC) (Fox et al., 2019). The incidence of DIC ranges from 0.03 percent to 0.35 percent, with developing countries having higher incidences (Erez et al., 2022). DIC occurs in response to placental abruption, ASP, fetal demise, sepsis, and preeclampsia. Symptoms of DIC are bleeding, petechiae, fever, hypotension, hypoxia, and localized hemorrhage. Treatment is correcting the initial cause of DIC. Other treatments are blood and blood-product replacement, intubation, and ventilation. Nurses are aware of the risk of DIC with preeclamptic persons who also have HELLP syndrome (Erez, 2022). See Chapter 12 Pregnancy at Risk for a thorough discussion of DIC.