You are in Mozambique volunteering at a birthing center. The midwives are entirely African nationals who will have no backup once you depart. One evening reflecting on this fact you determine to vigilantly transfer your skills to permanent staff. At that moment a voice comes from the door, “The baby will not come down and the heartbeat is falling!”
You trot to the birthing center to find two midwives surrounding a young lady. Her uterus is term in size and the fetal heart rate is 90. This is her second vaginal delivery, her cervix is fully dilated, and she has been pushing for four hours – far longer than to be expected.
You explain to the midwives to be cautious, for this woman is at increased risk for ALL but which ONE of the following?
A Postpartum infection
B Postpartum hemorrhage
C Lacerations of the birth canal
D Shoulder dystocia
E Preeclampsia
Please select your answer before reading on to the explanation to this intriguing question of clinical wisdom. The correct answer is E. Preeclampsia, also called toxemia of pregnancy, is a disorder of late pregnancy characterized by hypertension, edema, and proteinuria. Risk factors for preeclampsia include first delivery and multiple gestation, but not prolonged labor. Postpartum infection, postpartum hemorrhage, lacerations of the birth canal, and shoulder dystocia are all commonly associated with prolonger second stage of labor – the interval between full cervical dilatation and delivery.
You recommend draining the bladder with a catheter to open the birth canal. You also call for administration of oxygen, which remarkably is indeed available. The fetal heart rate rises to 130 between contractions. The baby begins to descend with the mother’s forceful pushing and minutes later the head is delivered. The mother continues to push. The midwife applies gentle traction on the head but the head will not further descend.
At this moment you recommend which ONE of the following actions?
A Administration of IV oxytocin
B Application of suprapubic pressure
C Application of increased traction on the fetal head
D Symphesiotomy
E Replacement of the fetal head into the uterus
Please select your answer before reading on to the explanation to this, another intriguing question of clinical insight. The correct answer is B. This complication is shoulder dystocia. It is caused by impaction of the fetal shoulder against the maternal pubis. Increasing uterine pressure via oxytocin or increasing traction of the fetal head will not relieve the impaction and may lead to serious injury of the infant. Effective management of shoulder dystocia calls for specified maneuvers that include suprapubic pressure to compress the impacted shoulder, internal rotation of the impacted shoulder, and extreme flexion of the mother’s legs at the hips. Symphysiotomy and replacement of the fetal head into the uterus (anesthesia required) are maneuvers of last resort.
Shoulder dystocia can be one of the most frightening delivery room emergencies. Yet basic maneuvers usually lead to successful delivery. Attaining such skills is well within the capability of primary care providers, and transferring these skills is one of the most effective roles for international healthcare volunteers. Please join us at the Exploring Medical Missions Conference for an introduction to managing such common delivery room emergencies, and other skills essential in serving forgotten people.