Obstetric Complications and Intrapartum Management
Core concepts
Know the mechanics and management of labor, including the partogram and definitions of labor protraction and arrest, the indications and techniques for operative vaginal delivery, and the management of shoulder dystocia, postpartum hemorrhage, and uterine rupture. Understand malpresentation (breech, transverse lie) and the role of external cephalic version. Understand preterm labor management: tocolysis for time to administer corticosteroids, magnesium for neuroprotection, and group B streptococcus prophylaxis.
Postpartum hemorrhage is a core emergency: know the causes (tone, trauma, tissue, thrombin), the sequence of uterotonics, tranexamic acid, balloon tamponade, and the decision for hysterectomy. Placenta accreta spectrum requires a multidisciplinary planned delivery.
Traps
- Diagnosing labor arrest before adequate dilation and descent criteria are met.
- Using fundal pressure in shoulder dystocia (contraindicated).
- Forgetting that uterine rupture presents with fetal bradycardia and loss of station, not always with pain.
- Misclassifying early postpartum hemorrhage from uterine atony as inevitable rather than treatable.
- Overlooking that a trial of labor after cesarean requires appropriate candidate selection and monitoring.
Rule of thumb
In any intrapartum emergency, follow the sequence: call for help, position the patient, assess fetal status, and act on the most life-threatening cause first. For shoulder dystocia, remember HELPERR as a mnemonic for sequential maneuvers.
Worked example: After delivery, a patient has heavy bleeding with a boggy uterus. Uterine massage and oxytocin are given, then tranexamic acid, then additional uterotonics. If bleeding persists, balloon tamponade and preparation for operative intervention are the next steps.