What are the primary recommendations for managing parturition to minimize risks to the mother and fetus?

Management of Parturition to Minimize Maternal and Fetal Risks

For routine term parturition, active management of the third stage with oxytocin (10-40 units in 1000 mL IV infusion or 10 units IM after placental delivery) is the primary intervention to prevent postpartum hemorrhage, while maintaining left lateral positioning during labor prevents aortocaval compression and optimizes uteroplacental perfusion. 1, 2

Positioning During Labor and Delivery

• Keep patients in left pelvic tilt or left lateral position after 20 weeks gestation to prevent supine hypotension syndrome, which occurs when the gravid uterus compresses the aorta and inferior vena cava, decreasing venous return and causing placental hypoperfusion and fetal hypoxia 2
• This positioning is critical throughout labor and any procedures to maintain cardiac return and prevent maternal hypotension 2

Third Stage Management: Prevention of Hemorrhage

• Administer oxytocin immediately after placental delivery using either 10-40 units added to 1000 mL non-hydrating diluent as IV infusion at a rate necessary to control uterine atony, or 10 units IM 1
• Active management of the third stage reduces postpartum hemorrhage risk, which occurs in 2.5-5% of deliveries and is increased in women with certain medical conditions 2
• Avoid prostaglandin F2α in women with asthma as it may cause bronchoconstriction, though clinical exacerbations are rare 2
• Avoid ergometrine in women with respiratory disease due to risk of bronchospasm, particularly with general anesthetics 2

Analgesia and Anesthesia Considerations

• Prioritize epidural analgesia over systemic opioids in women with respiratory disease, as opioids suppress cough, suppress ventilation, and may induce bowel obstruction 2
• Cautiously titrated epidural provides optimal pain relief while allowing early mobilization and minimizing respiratory depression 2
• For women on long-term systemic corticosteroids (≥7.5 mg daily for ≥2 weeks), administer stress-dose hydrocortisone IV during active labor and cesarean section due to potential hypothalamic-pituitary-adrenal axis suppression 2

Monitoring and Oxygen Support

• Maintain normal oxygen saturation with supplemental oxygen as needed during labor, particularly in women with chronic airways disease who may experience increased dyspnea, pain, and desaturation 2
• Provide bronchodilator therapy and assist with sputum clearance as needed during labor 2
• Consider positive end-expiratory pressure in women with established bronchiectasis to splint open smaller airways and improve secretion mobilization 2

Special Populations: Anticoagulated Patients

For women with mechanical heart valves requiring anticoagulation:

• Switch from warfarin to continuous IV unfractionated heparin (UFH) at least 36 hours before planned delivery, maintaining aPTT ≥2 times control 2
• Stop IV heparin 4-6 hours before planned delivery to reduce maternal bleeding risk and allow safe epidural placement 2
• If labor begins while on warfarin, perform cesarean section after anticoagulation reversal to prevent fetal intracranial hemorrhage, as warfarin crosses the placenta and anticoagulates the fetus 2
• Coordinate exact timing with obstetrics and anesthesia teams for epidural safety 2

Post-Delivery Care

• Mobilize patients early postpartum to reduce venous thromboembolism risk; consider low-molecular-weight heparin thromboprophylaxis if immobility persists 2
• Monitor women on long-term corticosteroids closely for poor wound healing and infection, especially after cesarean section 2
• Resume breastfeeding once the mother has recovered from sedation and is alert and awake, without need to pump and discard 2

Common Pitfalls to Avoid

• Never allow patients to lie supine after 20 weeks gestation during procedures or labor, as this causes aortocaval compression 2
• Do not withhold appropriate analgesia from patients with complex medical conditions, as inadequate pain control can trigger adverse physiologic responses 2
• Avoid oversedation that causes maternal hypotension or hypoxia, as this decreases placental blood flow and can lead to fetal distress 2
• Do not use prostaglandin F2α for postpartum hemorrhage in asthmatic patients due to bronchoconstriction risk 2

Ethical Framework for Decision-Making

• Maternal medical benefit takes priority when maternal and fetal benefit intractably conflict, though the pregnant patient may autonomously choose to prioritize perceived fetal benefit over their own medical benefit 2
• Counseling must exclude interventions where there is absence of reasonable evidence for fetal benefit 2
• Documentation of counseling and shared decision-making is essential and should be readdressed if clinical scenarios change 2