Flat on Her Back — Aortocaval Compression in Active Labor
Flat on Her Back — Aortocaval Compression in Active Labor - Obstetrics & Gynecology clinical simulation case. A 28-year-old G2P1 at 38 weeks gestation in...
A 28-year-old G2P1 at 38 weeks gestation in active labor (5 cm dilated, 80% effaced, contractions every 2–3 minutes) develops sudden hypotension, bradycardia, pallor, nausea, and category III fetal heart tracing with recurrent late decelerations shortly after being placed supine for continuous external fetal monitoring. She is diaphoretic, dizzy, and reports feeling like she might pass out.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Recognition of Supine Hypotension & Aortocaval Compression
In any pregnant patient beyond 20 weeks gestation, supine positioning can compress the IVC and aorta against the vertebral column, dropping venous return by 25–30% and causing 'supine hypotensive syndrome of pregnancy' — manifested by hypotension, bradycardia, nausea, syncope, and fetal late decelerations.
The immediate, definitive treatment is left uterine displacement via >15° left lateral tilt (manual, wedge, or full left lateral decubitus). Resolution of maternal vitals and normalization of the fetal tracing within 60–90 seconds CONFIRMS the diagnosis.
Vasopressors, atropine, tocolytics, and amniotomy do NOT treat the underlying mechanical obstruction and can worsen the picture. Treat the cause (position), not the symptom (hypotension).
A single, fully reversed aortocaval compression event is NOT an indication for cesarean delivery. Document and enforce left lateral tilt for the remainder of labor, including during epidural placement (with co-load) and second-stage pushing (lateral or upright).
Any procedure involving a pregnant patient — anesthesia, imaging, resuscitation — must begin with left uterine displacement. 'Flat on her back' is never an acceptable position in late pregnancy.
Test Your Clinical Reasoning in Real Time
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