Fetal Distress

Fetal distress (increasingly termed "suspected fetal compromise" in contemporary guidelines, reflecting the imprecision of the older term) refers to evidence, most commonly from cardiotocography, of inadequate fetal oxygenation during labor, requiring prompt evaluation and, where confirmed and significant, expedited delivery.

Underlying causes include cord compression, placental insufficiency, uterine hyperstimulation (excessive contraction frequency reducing intervillous blood flow), maternal hypotension, and any of the acute causes covered in dedicated entries (abruption, uterine rupture, cord prolapse).

Cardiotocography interpretation is systematic, assessing baseline rate (normal 110 to 160 bpm), variability (normal 5 to 25 bpm), the presence and type of decelerations (early decelerations, mirroring contractions, are generally benign and reflect head compression; variable decelerations reflect cord compression and are concerning if atypical, deep, or prolonged; late decelerations, with the nadir occurring after the peak of the contraction, indicate uteroplacental insufficiency and are the most concerning pattern), and the presence of accelerations (reassuring)
Traces are classified as normal, suspicious, or pathological (terminology and specific criteria vary slightly by guideline, e.g. NICE), guiding the urgency of the response
Fetal blood sampling (scalp pH and/or lactate) may be used where available to further evaluate a pathological trace before committing to immediate delivery, where clinical circumstances allow time for this: a pH above 7.25 (or lactate below 4.2 mmol/L) is reassuring, 7.21 to 7.24 (lactate 4.2 to 4.8) is borderline and repeated, below 7.20 (lactate above 4.8) indicates significant acidosis requiring expedited delivery
Fetal scalp stimulation, an acceleration in response to digital stimulation of the fetal scalp is reassuring and can avoid the need for fetal blood sampling in some cases

Conservative measures first, where the situation allows: maternal repositioning (left lateral, to relieve aortocaval compression), correction of maternal hypotension (IV fluid bolus, particularly relevant after epidural top-up), stopping oxytocin infusion if uterine hyperstimulation is contributing, and, where hyperstimulation is significant, tocolysis with terbutaline 250 mcg SC to acutely reduce contraction frequency
Maternal oxygen administration has not been shown to improve fetal outcomes and is not routinely recommended
Persistent pathological trace not responding to conservative measures, or a clearly ominous pattern (prolonged bradycardia, or acidosis confirmed on fetal blood sampling), warrants expedited delivery: instrumental vaginal delivery if fully dilated and criteria are met, or emergency cesarean section (category 1 if immediately life-threatening, category 2 if urgent but not immediately life-threatening)
Continuous reassessment and clear communication with the woman and her birth partner throughout, given the anxiety this situation understandably generates
Neonatal team present at delivery for any significant fetal distress, with cord blood gas sampling at delivery to objectively assess the degree of any acidosis at birth

Referral: obstetric-led care throughout labor; immediate senior obstetric involvement for any pathological CTG trace not resolving with initial conservative measures.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Uterine Rupture

Complete or partial disruption of the uterine wall during pregnancy or labor, a catastrophic obstetric emergency carrying high maternal and fetal mortality if not immediately recognized and managed.

The strongest risk factor is a previous cesarean section or other uterine surgery (myomectomy, previous rupture), particularly with a classical (vertical) uterine incision, which carries a substantially higher rupture risk than a lower segment transverse incision.

Other risk factors include obstructed labor (see that entry, a major cause in settings with limited cesarean access), injudicious oxytocin use, grand multiparity, and uterine over-distension (multiple pregnancy, polyhydramnios).

Sudden, severe abdominal pain, often described as tearing, sometimes with a brief cessation of contractions after previously strong labor
Sudden, sustained fetal bradycardia or other severe CTG abnormality is frequently the first and most reliable sign, particularly in a trial of labor after cesarean, and should prompt immediate consideration of rupture
Vaginal bleeding, though this may be minimal despite significant intra-abdominal hemorrhage
Loss of station of the presenting part (the fetal head, previously engaged, becomes palpable higher or is no longer palpable on vaginal examination) as the fetus extrudes into the abdominal cavity
Maternal tachycardia, hypotension, and signs of hypovolemic shock, which may be disproportionate to visible blood loss given concealed intraperitoneal hemorrhage
Scar tenderness in a woman with a previous cesarean section attempting vaginal birth

Primarily clinical, given the need for immediate action; imaging is not used to confirm the diagnosis in the acute setting, since any delay for imaging risks maternal and fetal death.

The combination of sudden fetal bradycardia, severe abdominal pain, and maternal hemodynamic compromise, particularly in a woman with a uterine scar or obstructed labor, should prompt immediate emergency laparotomy without waiting for further confirmatory testing.

Immediate emergency laparotomy is the definitive management, with delivery of the fetus and repair or, where repair is not feasible or bleeding is uncontrollable, hysterectomy
Call for senior help immediately: senior obstetrician, senior anesthetist, and theatre team activated as a maximum obstetric emergency
Aggressive maternal resuscitation as for any major hemorrhage: two large-bore IV access, crossmatched blood, activation of the massive transfusion protocol as needed (see Postpartum Haemorrhage entry for detailed transfusion principles)
Uterine repair is attempted where the rupture is amenable and future fertility is desired and feasible; hysterectomy is performed where repair is not possible or bleeding cannot otherwise be controlled
Neonatal resuscitation team present at delivery given the high risk of severe fetal hypoxia
Counseling regarding future pregnancy: subsequent pregnancies after uterine rupture are managed with planned cesarean delivery, typically before the onset of labor, given the substantially elevated recurrence risk with any subsequent labor

Referral: this is a maximum obstetric emergency requiring immediate senior obstetric, anesthetic, and theatre team activation.

Fetal Distress

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management