How to manage fetal distress in a pregnant patient at a primary level before referral?

Management of Fetal Distress at Primary Level Before Referral

Immediately initiate intrauterine resuscitation measures while simultaneously arranging urgent transfer to a higher-level facility, as stabilizing the mother will typically stabilize the fetus and most fetal heart rate abnormalities improve with maternal hemodynamic optimization. 1, 2

Immediate Intrauterine Resuscitation Protocol

Maternal Positioning

• Place the patient in left lateral recumbent position first to relieve aortocaval compression and improve uteroplacental blood flow 2, 3
• If fetal heart rate does not improve within 2-3 minutes, reposition to right lateral or knee-elbow position 2
• Maintain lateral tilt positioning until delivery to avoid aortocaval compression 3

Fluid Resuscitation

• Rapidly infuse 1 liter of non-glucose crystalloid intravenously to improve maternal blood volume and placental perfusion 2
• Maternal hypotension causes reduced placental blood flow, and fetal hypoxia becomes apparent shortly after maternal hemorrhage and hypovolemia 1

Oxygen Administration

• Administer maternal oxygen at the highest practical inspired percentage (typically 100% via non-rebreather mask) to maximize oxygen delivery to the fetus 2, 4

Tocolysis for Uterine Activity

• If uterine contractions are present, immediately discontinue oxytocin if it is being administered 4
• Administer terbutaline 250 mcg subcutaneously or intravenously to inhibit uterine contractions and improve placental blood flow 2
• This reduces uterine oxygen consumption and improves intervillous blood flow 4

Amnioinfusion (If Equipment Available)

• Consider intra-amniotic infusion of warmed crystalloid solution if variable decelerations suggest cord compression and equipment is available 2
• This may alleviate umbilical cord compression by increasing amniotic fluid volume 2

Specific Maneuvers for Cord Prolapse

• If umbilical cord prolapse is identified, manually elevate the presenting fetal part to relieve cord compression 2
• Maintain this position during transfer 2

Critical Transfer Considerations

Timing and Stabilization

• Stabilize the patient before transport using the above measures 1
• Do not delay transfer waiting for complete resolution of fetal heart rate abnormalities 1
• Avoid delays in transporting a critically ill pregnant patient due to inability to monitor the fetus—stabilizing the mother will typically stabilize the fetus 1

Transfer Criteria

• Transfer should be arranged to a facility with:
  • Immediate cesarean delivery capability 1
  • Neonatal resuscitation team 1
  • Obstetric anesthesia services 1

During Transport

• Continue maternal oxygen administration 2
• Maintain lateral positioning 3
• Continue intravenous fluid administration 2
• If delivery appears imminent during transport, it may be safer to deliver at the primary facility rather than risk delivery en route 1

Fetal Monitoring Interpretation

Recognize Reversible vs. Irreversible Causes

• Potentially reversible causes include uterine hyperstimulation, maternal hypotension, and aortocaval compression—these respond to intrauterine resuscitation 1
• Irreversible causes include major placental abruption, fetal hemorrhage, ruptured uterine scar with fetal extrusion, and umbilical cord prolapse with sustained bradycardia—these require immediate delivery 1

Expectant Management During Stabilization

• Fetal heart rate tracing may be expectantly managed during initial stabilization, as most will improve with maternal hemodynamic optimization 1
• Fetal condition is maintained during delays in the majority of cases with reversible causes 1

Common Pitfalls to Avoid

• Do not perform manual removal of placenta at primary level except in cases of severe uncontrolled hemorrhage, as this requires expertise, adequate analgesia, and aseptic conditions 1
• Do not delay transfer to attempt complete normalization of fetal heart rate—ongoing resuscitation can continue during transport 1, 2
• Recognize that fetal distress can occur before maternal deterioration, so normal maternal vital signs do not exclude fetal compromise 1
• The majority of fetuses with non-reassuring fetal heart rate patterns are neurologically intact, but this should not delay appropriate intervention and transfer 5