# Clinical Cases: Cesarean Delivery and Operative Obstetrics ## Case 1: Emergency Cesarean for Non-Reassuring Fetal Status ### Patient Demographics - **Age:** 29 years - **Sex:** Female - **Occupation:** Marketing manager ### Chief Complaint "I'm in labor and something seems wrong with the baby's heartbeat." ### History of Present Illness The patient is G1P0 at 39 weeks 4 days admitted in spontaneous labor. She presented with regular contractions and ruptured membranes with clear fluid. Initial cervical exam was 5 cm dilated. Labor progressed normally until she reached 8 cm dilation when the fetal heart rate tracing became concerning. ### Labor Course **Admission:** - Cervix: 5 cm, 80% effaced, 0 station - FHR: Baseline 140, moderate variability, accelerations present - Membranes ruptured; clear fluid **At 8 cm (6 hours after admission):** - Epidural in place, comfortable - Contractions every 2-3 minutes - FHR changes noted: - Baseline rising to 170 bpm (tachycardia) - Variability decreased to minimal - Recurrent late decelerations with each contraction ### Fetal Heart Rate Interpretation **Category III Tracing:** - Absent variability with recurrent late decelerations - Indicative of ongoing fetal hypoxia/acidosis ### Intrauterine Resuscitation Attempted **Interventions:** 1. Position changes (left lateral, right lateral, hands and knees) 2. IV fluid bolus (1 L lactated Ringer's) 3. Oxygen by face mask at 10 L/min 4. Discontinue oxytocin (was running for augmentation) 5. Cervical exam: 8 cm, no cord prolapse **Response:** - No improvement after 10 minutes - Persistent late decelerations with minimal variability - Decision: Emergency cesarean delivery ### Cesarean Delivery **Indication:** Non-reassuring fetal status (Category III tracing unresponsive to resuscitation) **Timing:** Decision-to-incision interval: 15 minutes **Procedure:** - Pfannenstiel skin incision - Low transverse uterine incision - Delivery of male infant in cephalic presentation - Nuchal cord x 1 reduced at delivery - Moderate meconium-stained fluid noted (not present on initial ROM) ### Neonatal Outcome - Male infant, 3,450 grams - Apgar scores: 5/7/9 (1, 5, 10 minutes) - Cord gases: pH 7.08, base excess -12 (metabolic acidosis) - Vigorous at birth after stimulation - NICU observation for 4 hours, then to newborn nursery - No sequelae at discharge ### Postoperative Course - Routine post-cesarean recovery - Ambulating POD 1 - Tolerating regular diet - Hemoglobin stable - Discharged POD 3 ### Counseling for Future Pregnancies - Discussion of TOLAC vs. elective repeat cesarean - Low transverse incision: eligible for TOLAC in future pregnancy - Success rate for TOLAC without prior vaginal delivery: 60-70% - Uterine rupture risk with low transverse: 0.5-1% ### Clinical Image ![Category III FHR Tracing](case_01_image.jpg) **Image Description:** Fetal heart rate tracing demonstrating Category III pattern with absent variability and recurrent late decelerations. The tracing shows a rising baseline with minimal beat-to-beat variability and late decelerations that begin after the peak of contractions and return to baseline after the contraction ends. **Attribution:** Educational illustration. Adapted from ACOG fetal heart rate interpretation guidelines. --- ## Case 2: Trial of Labor After Cesarean (TOLAC) Complicated by Uterine Rupture ### Patient Demographics - **Age:** 33 years - **Sex:** Female - **Occupation:** Pharmacist ### Chief Complaint "I'm having contractions and I want to try for a vaginal delivery this time." ### History of Present Illness The patient is G2P1 at 39 weeks 1 day with spontaneous onset of labor. Her prior pregnancy resulted in a cesarean delivery for breech presentation at 39 weeks (low transverse incision confirmed by operative report). She desires TOLAC. She has been contracting regularly for 4 hours and presents for admission. ### Prenatal Course - Uncomplicated pregnancy - TOLAC counseling completed at 36 weeks - Reviewed operative report: confirmed low transverse incision - Discussed risks and benefits, signed consent for TOLAC ### TOLAC Candidacy Assessment - Prior low transverse cesarean incision: YES - Non-recurring indication (breech): YES - Singleton vertex pregnancy: YES - Spontaneous labor onset: YES - Interpregnancy interval >18 months: YES (30 months) - Estimated success rate: 70-75% ### Admission - Cervix: 4 cm, 90% effaced, -1 station - FHR: 140 bpm, moderate variability, accelerations present - Contractions: Every 3 minutes, strong by palpation - IV access established, type and screen current - Anesthesia aware, epidural placed for labor analgesia ### Labor Progress **Hour 3:** - Cervix: 6 cm - FHR: Reactive, no decelerations - Contracting well, no augmentation needed **Hour 5:** - Cervix: 8 cm - FHR: Variable decelerations, quickly recovering - Patient comfortable with epidural **Hour 6 - ACUTE EVENT:** - Patient reports sudden, severe abdominal pain "different from contractions" - States pain persists even between contractions - Epidural in place, but she rates pain 9/10 despite it **Immediate Assessment:** - FHR: Prolonged deceleration to 60 bpm - Maternal HR: 110 bpm (new tachycardia) - Abdominal exam: Diffuse tenderness, uterine contour difficult to palpate - Vaginal exam: Cervix still 8 cm, presenting part now at -3 station (was -1) - **Loss of fetal station noted** ### Diagnosis **Suspected Uterine Rupture** - Classic triad: sudden severe pain, FHR abnormality, loss of station - Prolonged fetal bradycardia not recovering ### Emergency Cesarean Delivery **Decision-to-incision:** 8 minutes (crash cesarean) **Operative Findings:** - Pfannenstiel incision through prior scar - Upon entry to abdomen: Hemoperitoneum (~800 mL blood) - **Complete uterine rupture** along prior incision site - Fetal arm palpated through rupture site - Baby partially extruded into abdomen **Delivery:** - Female infant delivered through uterine incision - Limp, no spontaneous respirations initially - Apgar: 2/5/7 **Uterine Repair:** - 6 cm dehiscence of prior scar with extension into left broad ligament - Active bleeding from uterine arteries - Uterine repair performed in two layers - Hemostasis achieved - EBL: 1,800 mL - Received 2 units PRBCs intraoperatively ### Neonatal Outcome - Female, 3,280 grams - Cord gases: pH 6.95, base excess -16 (severe metabolic acidosis) - Required PPV and brief chest compressions - Intubated, NICU admission - Therapeutic hypothermia initiated for HIE protocol - Extubated day 3, MRI normal - Discharged home day 10, following with neurology ### Maternal Postoperative Course - ICU monitoring for 24 hours - Hemoglobin nadir 7.8, received additional 1 unit PRBCs - Transitioned to floor POD 2 - Discharged POD 5 ### Counseling - Future pregnancies: TOLAC contraindicated (prior rupture) - Recommended cesarean delivery at 36-37 weeks in any future pregnancy - Discussed recurrence risk and close monitoring if she becomes pregnant again ### Clinical Image ![Uterine Rupture](case_02_image.jpg) **Image Description:** Intraoperative photograph demonstrating complete uterine rupture along a prior low transverse cesarean incision. The myometrial edges are separated with visible hemoperitoneum, and the fetus is partially visible through the defect. **Attribution:** Educational illustration. Used for medical education purposes demonstrating uterine rupture recognition. --- ## Case 3: Shoulder Dystocia Management ### Patient Demographics - **Age:** 31 years - **Sex:** Female - **Occupation:** Physical therapist ### Chief Complaint "I'm pushing but the baby isn't coming out!" ### History of Present Illness The patient is G2P1 at 40 weeks 2 days with gestational diabetes (A2GDM on insulin). She had an uncomplicated first vaginal delivery of a 3,600-gram infant. She has been pushing for 90 minutes. The fetal head delivered with the last push, but the body has not followed despite continued maternal pushing and routine maneuvers. ### Prenatal Course - Gestational diabetes diagnosed at 26 weeks - Required insulin (NPH and lispro) - Glucose control: Fair (60% of values at goal) - 39-week growth ultrasound: EFW 4,100 grams (85th percentile) - Discussed risks of macrosomia, offered induction at 39 weeks; patient preferred spontaneous labor ### Labor Course - Spontaneous labor at 40+2 weeks - Progressed normally to complete dilation - Second stage: 90 minutes of pushing - Fetal head delivered to perineum with gentle crowning ### The Event: Shoulder Dystocia **Recognition:** - Head delivered but immediately retracts against perineum ("turtle sign") - Failure of external rotation (restitution) - Gentle downward traction on head: no delivery of shoulders - Anterior shoulder impacted behind pubic symphysis **Time Noted:** 14:32 (stopwatch started) ### HELPERR Protocol Initiated **H - Help:** - Called for additional nurses, obstetrician, pediatrics, anesthesia - Designated one person as timekeeper and documenter **E - Evaluate for Episiotomy:** - Midline episiotomy performed to create room for maneuvers **L - Legs (McRoberts Maneuver):** - Maternal thighs hyperflexed onto abdomen by assistants - Flattens sacrum, increases AP diameter of pelvis - Result: Shoulder still impacted **P - Pressure (Suprapubic):** - Continuous suprapubic pressure applied by assistant - Heel of hand pressing downward and laterally above symphysis - Applied while McRoberts maintained - Result: No delivery after 30 seconds **Time Check:** 14:34 (2 minutes) **E - Enter (Rotational Maneuvers):** - Rubin maneuver attempted: Hand inserted behind anterior shoulder, pushed anteriorly toward fetal face - Result: Partial rotation achieved but shoulder still impacted - Woods screw: Fingers placed on anterior aspect of posterior shoulder, rotated 180 degrees - Result: Successful rotation of posterior shoulder to anterior position **Time of Delivery:** 14:35 (3 minutes total) ### Delivery Outcome - Male infant, 4,350 grams (macrosomic) - Apgar scores: 6/8/9 - Initial assessment: Right arm limp, no spontaneous movement ### Neonatal Evaluation - **Right Erb's palsy identified:** - Waiter's tip position (arm adducted, internally rotated, wrist flexed) - Decreased grip strength - C5-C6 brachial plexus injury - No clavicle or humerus fracture on X-ray - Pediatric neurology consulted ### Maternal Outcome - Second-degree perineal laceration (repaired) - EBL: 450 mL - No other maternal injuries ### Follow-up **Infant (2 weeks):** - Right arm showing early recovery - Occupational therapy initiated - Family counseled that most Erb's palsies (80-90%) resolve within 3-12 months **Infant (3 months):** - Near-complete recovery of arm function - Continued OT exercises - Good prognosis ### Documentation - Detailed delivery note with times, maneuvers attempted, and order - Risk factors documented (GDM, macrosomia) - EFW and delivery discussions documented in prenatal chart ### Teaching Points - Shoulder dystocia is unpredictable - occurs without risk factors in 50% of cases - HELPERR mnemonic provides systematic approach - McRoberts + suprapubic pressure resolve most cases - Do NOT apply fundal pressure (worsens impaction) - Document meticulously: time, maneuvers, personnel present - Brachial plexus injury occurs in 10-20% of shoulder dystocia; most resolve ### Clinical Image ![Shoulder Dystocia Maneuvers](case_03_image.jpg) **Image Description:** Illustration demonstrating the McRoberts maneuver with maternal thighs hyperflexed onto the abdomen while an assistant applies suprapubic pressure. The diagram shows how these maneuvers flatten the sacrum, rotate the symphysis, and increase the anteroposterior diameter of the pelvis to facilitate delivery. **Attribution:** Educational illustration. Adapted from ALSO (Advanced Life Support in Obstetrics) guidelines.