Case 95: Labour

 CASE 95: LABOUR

History

A 22-year-old woman is admitted to the labour ward for induction of labour at 40 weeks’

gestation. This is her first ongoing pregnancy, having had a first-trimester miscarriage 13

months previously. She booked at 9 weeks and had normal booking blood tests. The 11–14-

week scan and 21-week anomaly scan did not show any obvious fetal abnormality. Blood

pressure and urinalysis have always been normal.

At her 32-week midwife appointment she reported feeling very uncomfortable abdominally,

and the midwife measured the symphysiofundal height to be 36 cm. A further ultrasound

scan was therefore requested which showed normal fetal growth but increased liquor volume.

She had been reviewed in the antenatal clinic and was tested for gestational diabetes with

glucose tolerance test but this was normal. Subsequent examinations had again confirmed

an increased symphysiofundal height, and further ultrasound scan at 36 weeks again showed

normal growth, no fetal abnormality and markedly increased liquor volume. The fetal movements had always been normal.

A decision had been made for induction of labour at 40 weeks because the woman had become

so uncomfortable and breathless.

On palpation the fetus was cephalic with the head 4/5 palpable abdominally. Cardiotocograph

(CTG) was reassuring; 2 mg of prostaglandin gel had been inserted into the posterior fornix

of the vagina and CTG monitoring continued for a further 20 min.

The woman then mobilized and contractions started within an hour. She requested an epidural for analgesia and while this was being prepared CTG monitoring was commenced. At this

stage, spontaneous rupture of membranes occurred with a very large volume of clear liquor

soaking the bed sheets.

INVESTIGATIONS

The CTG is shown in Fig. 95.1.

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Figure 95.1 Cardiotocograph.100 Cases in Obstetrics and Gynaecology

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Questions

• Describe the CTG.

• What is the likely diagnosis?

• How would you confirm the diagnosis and manage this situation?Case 95: Labour

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ANSWER 95

The CTG shows deep atypical variable decelerations. The sudden CTG deterioration after

rupture of membranes in a woman with polyhydramnios suggests the likelihood of prolapse

of the cord. Other possible diagnoses are placental abruption or fetal head compression from

precipitate labour. The diagnosis is easily confirmed with vaginal examination. A loop of

umbilical cord will be palpated in the vagina and will be pulsatile.

! Risk factors for cord prolapse

• Polyhydramnios

• Preterm delivery

• Malpresentation

• Unstable presentation

• Multiple pregnancy

This is an obstetric emergency and the emergency bell should be activated with the senior midwife, theatre team, senior obstetrician, paediatrician and anaesthetist summoned immediately.

The important management steps are:

• the examiner should not remove their fingers from the vagina and should attempt to elevate the fetal head above the cord and minimize contact with the cord to prevent spasm

• the woman should be rotated into the ‘all-fours position’ (head lower than buttocks),

which will facilitate relieving the weight of the baby and abdomen from the prolapsed cord

• she should be transferred to theatre immediately for caesarean section

• intravenous access should be obtained, and a general anaesthetic administered,

using a rapid sequence induction with cricoid pressure

• the examiner should only remove their fingers from the presenting part in the

vagina when the uterus has been opened and the baby is being delivered.

KEY POINTS

• Cord prolapse should be suspected in cases of fetal heart abnormality occurring

after rupture of membranes.

• It is an obstetric emergency and necessitates immediate caesarean section.

• Attempts should be made to minimize pressure on the cord pending delivery.