Late decelerations in a prolonged second stage at a rural primary unit
At a rural primary maternity unit 50 minutes by road from the tertiary hospital, a 31-year-old para 1 at 40+5 weeks is in the second stage of spontaneous labour. She has been pushing for 1 hour 50 minutes. The fetal heart baseline is 150 bpm with moderate variability. Over the last 20 minutes there have been three late decelerations to 90 bpm, each lasting about 60 seconds and recovering after the contraction. Maternal observations are BP 110/70 mmHg, pulse 90 bpm, temperature 37.8°C, and urine output is adequate. There is no oxytocin running. The midwife is the LMC and the only midwife on site; a second midwife is 20 minutes away. The woman is becoming exhausted and asks for an epidural, which is not available locally. The nearest operating theatre and paediatric team are at the tertiary hospital. The ambulance is available but the helicopter is on another task.
1. Interpret the fetal heart pattern and outline your immediate intrauterine resuscitation and birth-planning decisions.
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Interpretation: a baseline of 150 bpm with moderate variability and recurrent late decelerations is not reassuring. Late decelerations suggest uteroplacental insufficiency, even in the second stage. I would also exclude maternal hypotension, dehydration, uterine hyperstimulation and a full bladder, and perform a vaginal examination to assess descent, position and to exclude cord prolapse.
Immediate actions: reposition to left lateral, give IV fluids, stop any oxytocin (none is running), empty the bladder, continue continuous CTG, and avoid routine oxygen unless she is hypoxaemic. I would coach pushing only with contractions and avoid prolonged breath-holding. Because she is at a primary unit with no operating theatre and the pattern is abnormal in a prolonged second stage, I would plan urgent transfer. If birth is imminent, I would prepare for birth and newborn resuscitation on site. If birth is not imminent, I would transfer by ambulance with a midwifery escort and request helicopter support if it becomes available. I would pre-alert the tertiary obstetric and neonatal teams.
The decision balances the risk of waiting against the risk of transferring a woman who may give birth en route. I would not delay transfer for an epidural. I would document the CTG interpretation, actions taken, response, vaginal findings, transfer decision and timings.
2. What are the key considerations for transfer and handover, including communication with the woman and whānau?
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I would explain that the baby’s heart pattern shows signs of stress and that the safest place for birth is now the tertiary hospital, while acknowledging her exhaustion and her wish for pain relief. I would be clear that an epidural is not available locally and that transfer is recommended because operative birth and neonatal care may be needed. I would ask who she wants contacted and involve her whānau in the way she chooses.
Operationally, I would call the ambulance, give the clinical details and estimated time of arrival, arrange a midwifery escort, secure IV access, monitor mother and baby continuously, and position her for comfort and placental perfusion. I would prepare a transfer bag with records, medications and newborn resuscitation equipment. I would use a structured handover (SBAR) to the tertiary team: maternal history, labour progress, CTG findings and actions, observations, vaginal findings, transfer time and identified risks.
If birth occurs before transfer, I would call for the second midwife and ambulance backup, manage the birth and immediate newborn care, and document the sequence. Either way, I would document the informed discussion, her agreement or refusal, the transfer plan, who attended, and all times.