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“Unforgettable Red and Blue Alert”

Red AND blue alert in my hospital means either two things: cord prolapse or
shoulder dystocia.

Few years ago, a case of shoulder ‘D’ taught me a few golden points in life.

The mother was 19 years old, newly married and pregnant with her first child. She was screened for diabetes based on family history and diagnosed as ‘overt DM’. She was 35 weeks into her pregnancy, with her sugars relatively controlled by Metformin. She was 149cm tall, with a BMI of 29. She presented with preterm
prelabor rupture of membranes. I saw her in the antenatal ward on that fateful
Saturday oncall morning, palpated her abdomen and estimated the baby to be about 3.2 – 3.4kg, which corresponded to the admission ultrasound scan findings. I thought to myself that she should be delivering soon as the baby’s head was engaged and she had 1:10 contraction with os of 2cm.

At 1800H, the buzzer on the PA system went off, announcing the dreaded ‘RED AND
BLUE ALERT IN LABOR ROOM’. Running into the room, I found my medical officers
halfway through the HELPPER algorithm, attempting to deliver the baby. I quickly took over to perform the rotational and removal of posterior arm manoeuvre. It did not work! I started again from the top, even turning the patient on all-fours, but to no avail. For the first time in my 16 years as a doctor, I took a deep breath, tried to stay calm and asked the mother to turn on her back, and tried the mnemonic again. Preparing for the worst case scenario, I silently asked myself if I had the courage to break the baby’s clavicle.

Miraculously the baby was delivered by the posterior shoulder this time. I suspected that being on all-fours have helped relieved some pressure somewhere. The baby was born flat after 7 minutes of initiating for help. The Paediatric team who was on standby, resuscitated and intubated the baby, before admitting him to level 3 NICU. The 3.5kg baby survived 13 days before finally succumbing.

Upon reflection, I learnt to:

• Never underestimate a diabetic mother’s baby, as they can bring catastrophic surprises.
• Never underestimate a primigravida’s pelvis, especially in Sabah.