In fact, it is fair to say that the most widespread and potentially dangerous intervention during labor is the administration of oxytocin. Many expert opinions, guidelines, and strategies have been put forward about intrapartum use of oxytocin. These include consideration of:
- indications
- dosage (including the maximum)
- interval
- fetal response
- ultimately, the availability of a physician during administration to manage any problem that arises.
Considerations in CASE 2
- Always clearly indicate the reason for using oxytocin: Is this an induction? Or an augmentation? Was there evidence of fetal well-being, or non-reassurance, before oxytocin was administered? Certainly, there are circumstances in which either fetal status or non-progression of labor (or both) are an indication for oxytocin. A clear, concise, and properly timed progress note is always appropriate under these circumstances.
- Discuss treatment with the patient. Does she understand why this therapy is being recommended? Does she agree to its use? And does she understand what the alternatives are?
- Verify that nursing has accurately charted this process. Ensure that the nursing staff’s notes are complete and are consistent with yours.
- Simplify the entire process: Use premixed solution and protocol-driven orders. Know what the standards and protocols are in your department. Minimizing patient-to-patient variability should lessen the risk of error.
- Always be available in L & D for the first 30 minutes that oxytocin is being administered. If a problem with excessive uterine activity is going to occur, it is most likely to do so upon initial administration.
- Monitor the FHR continuously. At the first suggestion of a change in fetal status, discontinue oxytocin. Perform a pelvic exam to reassess the situation. Understand and apply appropriate inutero resuscitative measures (IV fluids, O2, change in maternal position). Depending on circumstances, you can consider a restart of oxytocin after the FHR returns to its pre-oxytocin pattern.
- Monitor uterine response to oxytocin. If the membranes are ruptured and if it is clinically feasible, an intrauterine pressure transducer will allow you to more objectively assess the uterine response to oxytocin and make decisions on that basis. Determine beforehand whether the patient is agreeable to this intervention.
- When oxytocin is used for augmentation, reassess labor within 4 hours of achieving a satisfactory pattern. If minimal progress is not made, assess the clinical situation to determine why oxytocin, at an adequate response level, has failed to return labor to a normal active phase slope. Are there minor degrees of malposition? Is there an element of cephalopelvic disproportion? Recall that progress in labor is dependent on multiple factors.
- Chart the process concurrently. Specify options for delivery before delivery.
CASE 3: Spontaneous delivery arrests after delivery of the head
The patient is a multipara with three prior normal vaginal deliveries. Her diabetic screen is negative. At admission, the estimated fetal weight was 3,628 g—in the same range as her other deliveries. A nuchal cord is absent.
After the patient assumes the McRobert’s position, delivery is accomplished with suprapubic pressure. Weakness is noted in the newborn’s right upper extremity. Birth weight is 3,515 g.
Maneuvers to manage shoulder dystocia should be part of all clinicians’ skill set. The sequence of those maneuvers, and their timing, are subject to some variation. Efficacy seems to be related most to recognizing and performing each maneuver properly.
Guidelines for managing shoulder dystocia should include reference to 1) the initial evaluation of the patient on admission to labor and delivery and 2) the delivery itself.3
Considerations in CASE 3
- Before you admit them to L & D, counsel patients who have diabetes, morbid obesity (body mass index >40), or birth trauma in a prior delivery, or who have had a prior large infant (>9 lb birth weight), about the risk of shoulder dystocia. Present possible alternatives, and draw the patient into the conversation.
- Consider delivering all women at term in the McRobert’s position, prophylactically.
- Always check for a nuchal cord after delivery of the head. If you find one, reduce it if possible. Take a few seconds and carefully assess the situation before you cut the umbilical cord.
- Lateral traction on the fetus’ head has the potential to cause tension on the brachial plexus, or make it worse. Gentle rotation of the head (<90 degrees) can move the shoulders into a more favorable location for delivery. Don’t rush—call for assistance! Continuously explain to the patient what you are doing; reassure her about the process.
- Use suprapubic pressure wisely. The anterior shoulder may be dislodged by direct downward force; suprapubic force in a lateral direction may also dislodge the shoulder. Apply force from above the patient’s pelvis. Your assistant will have the best mechanical advantage by standing on a stool.
- Is an episiotomy or episioproctotomy advantageous? In attempting to reach either the anterior or posterior shoulder vaginally, individualized assessment is called for.
- When the posterior shoulder cannot be satisfactorily engaged and moved, try doing so with the anterior shoulder. Insert your hand between the symphysis and the fetal head and place downward pressure on the head to dislodge it and complete the delivery.
- If it becomes necessary to attempt delivery by direct traction on the posterior hand or arm, try to avoid extension. Maintain flexion and move the upper extremity across the fetal chest before you attempt extension.
- Repeat these maneuvers a second time before you attempt cephalic replacement or other maneuvers. Remember to move with deliberate speed to lessen the risk of making the injury worse. Have pediatric support present. Continue speaking with and reassuring the patient.
- Under anesthesia in the operating room, perform a hysterotomy incision. With an assistant working through the vagina, combine the forces available to complete the delivery.
- After delivery is complete, take time to write a note. (Speak with the patient and her family first, however.) Read the notes written by nursing. If they are not available when you write your note, mention that. Add a second note later, when nursing notes become available.