Most common, but potentially very dangerous complications of labour
The labour and birth process are generally straightforward, however, when complications arise the immediate attention of a qualified and experienced health care specialist is paramount. Any delays has the potential to increase the chance of injury or death to the baby or mother. As such, when complications arise, a prompt delivery of the baby and high quality care is the only way to ensure a healthy mother and baby.
Non-Reassuring Foetal Status
Non-reassuring foetal status (NRFS), also known as foetal distress, is used to describe a foetus that does not appear to be doing well. NRFS can be linked to an irregular heartbeat in the baby, problems with muscle tone and movement, and low levels of amniotic fluid.
Underlying causes and conditions can include:
- insufficient oxygen levels
- maternal anaemia
- pregnancy-induced hypertension in the mother
- intrauterine growth retardation (IUGR)
- meconium-stained amniotic fluid
NRFS is more likely to occur in pregnancies that continue after the due date. Strategies that may help include:
- changing the mother's position
- increasing maternal hydration
- maintaining oxygenation for the mother
- amnioinfusion, where fluid is inserted into the amniotic cavity to relieve pressure on the umbilical cord
- tocolysis, a temporary stoppage of contractions
- intravenous hypertonic dextrose
In some cases, an immediate delivery of the baby by instrumental or caesarean section is necessary.
Failure to progress
Labour that does not progress, or failure to progress is when labour lasts longer than expected. Studies suggest that this affects around 8 percent of those giving birth and occurs for a number of reasons.
The American Pregnancy Association defines prolonged labour as lasting more than 20 hours if it is a first delivery. For those who have previously given birth, failure to progress is when labour lasts more than 14 hours.
If prolonged labour happens during the early or latent phase, it can be tiring to the mother but does not usually lead to complications. In most cases, inserting an epidural will relax the mother and enable her to recoup some energy.
However, if it happens during the active phase, medical assessment and immediate intervention may be necessary.
Causes of prolonged labour include:
- slow cervical dilations
- slow effacement
- a large baby
- a small birth canal or pelvis
- delivery of multiple babies
- emotional factors, such as worry, stress, and fear
If labour fails to progress, the first recommendation is to relax and wait. The American Pregnancy Association advises taking a walk, having a nap, or running a warm bath. In the later stages, health professionals may give labour-inducing medications or recommend a caesarean delivery.
Perinatal asphyxia is defined as "failing to initiate and sustain breathing at birth". It can happen before, during or immediately after delivery due to an inadequate supply of oxygen and can lead to hypoxemia (low oxygen levels, high levels of carbon dioxide) or acidosis (too much acid in the blood). Cardiovascular problems and organ malfunction may occur as a result. Before delivery, symptoms may include a low heart rate and low pH levels, indicating high acidity.
Other indications may include:
- poor skin colour
- low heart rate
- weak muscle tone
- weak breathing
- meconium-stained amniotic fluid
Treatment of perinatal asphyxia can include providing oxygen to the mother, or carrying out an immediate delivery by instrumental or caesarean section. After delivery, mechanical breathing or medication may be necessary.
Shoulder dystocia is when the head is delivered vaginally but the shoulders remain inside the mother. It is not a common scenario and tends to affect women who have not given birth before, have large babies and suffer from gestational diabetes. Immediate qualified interventions is necessary.
Health providers will apply specific manoeuvres to release the shoulders, such as changing the mother's position and manually turning the baby's shoulders. An episiotomy, or surgical widening of the vagina, may be needed to make room for the shoulders.
Complications are usually treatable and temporary. However, if a non-reassuring foetal heart rate is also present, this may indicate further problems.
Maternal complications include uterine, vaginal, cervical or rectal tearing and heavy bleeding after delivery.
On average, a woman loses 300-500 mL of blood during a vaginal delivery of a single baby. During a caesarean delivery for a single baby, the average amount of blood lost is slightly higher.
Postpartum haemorrhage (PPH) can occur within 24 hours after delivery or up to 12 weeks later, known as secondary bleeding. Around 80 percent of cases of PPH result from a lack of uterine tone.
Bleeding happens after the placenta is expelled, because the uterine contractions are too weak and cannot provide enough compression to the blood vessels at the site of where the placenta was attached to the uterus.
Low blood pressure, organ failure, shock, and even death can result if immediate interventions aren’t employed by an experienced and qualified health professional.
Certain medical conditions and treatments can increase the risk of developing PPH and they should be considered before labour and delivery. These include:
- placental abruption, placenta previa and placenta accreta need to be excluded
- uterine overdistention by multiple gestation pregnancy and polyhydramnios (lots of fluid around the baby)
- pregnancy-induced hypertension
- multiple prior births or prolonged labour
- use of general anaesthesia or medications to induce or stop labour
- infection and obesity
Other medical conditions that can lead to a higher risk, such as cervical, vaginal or uterine blood vessel tears, haematoma of the vulva, vagina or pelvis, blood clotting disorders, uterine rupture, will need to be looked into.
Treatment aims to stop the bleeding as soon as possible and replace any blood loss and include:
- the use of medication and uterine message
- removal of retained placenta
- uterine packing
- tying off bleeding blood vessels
- surgery, possible a laparotomy, to find the cause of the bleeding, or even a hysterectomy to remove the uterus if all other measurements fail.
Excessive bleeding can be life-threatening, but with rapid and appropriate specialised medical help, the outlook is normally good.
Not all babies will be in the best position for vaginal delivery. Facing downwards is the most common foetal birth position, but babies can be in other positions, such as:
- Occipital posterior (baby facing upward)
- Breech, either buttocks first (frank breech) or feet first (complete breech)
- Lying horizontally across the uterus, instead of vertically
Depending on the position of the baby and the situation, it may be necessary to manually change the foetal position, use forceps, carry out an episiotomy to surgically enlarge the opening or perform a caesarean delivery.
Problems with the umbilical cord can be very dangerous and include;
- cord becoming wrapped around the baby
- compressed or rarely
- a prolapsing (cord emerging before the baby)
If the cord is wrapped around the baby’s neck, compressed or prolapses, immediate specialist level intervention will probably be needed.
When the placenta covers the opening of the cervix, this is referred to as placenta previa. This is a dangerous situation and a caesarean delivery is often necessary. It affects around 1 in 200 pregnancies in the third trimester.
It is more likely to occur in those patients who:
- have had previous deliveries, and especially four or more pregnancies
- previous placenta previa, caesarean delivery, or uterine surgery
- have a multiple gestation pregnancy
- are aged over 35 years and are smokers
- have uterine fibroids
The main symptom is bleeding without pain during the second and third trimester. This can range from light to heavy. Other possible indications include early contractions and the baby being in breech position.
Treatment is usually bed rest or supervised rest in the hospital. However in severe cases where bleeding does not stop or the foetal heart reading is non-reassuring, blood transfusion and/or immediate caesarean delivery is necessary.
Placenta Previa can increase the risk of a condition known as placenta accreta, a life-threatening condition in which the placenta becomes inseparable from the wall of the uterus. This could be the most dangerous situation, especially if not diagnosed prior to labour and delivery. Highly experienced specialist care is recommended.
Cephalopelvic disproportion (CPD)
CPD is when a baby's head is unable to fit through the mother's pelvis. According to the American College of Nurse Midwives, cephalopelvic disproportion occurs in 1 in 250 pregnancies.
This can happen if; the baby is large or has a large head size, the baby is in an unusual position, the mother's pelvis is small or has an unusual shape. A caesarean delivery will normally be necessary.
If someone has previously had a caesarean delivery and especially if the ‘double layer closure technique’ was not used, there is a chance that the scar could open during a future labour. If this happens, the baby may be at risk of oxygen deprivation and immediate caesarean delivery is necessary. The mother may be at risk of excessive bleeding and her life may be in danger.
Apart from a previous caesarean delivery, other possible risk factors include the size of the baby and maternal age of 35 years or more.
Women who plan for a vaginal birth after previously having a caesarean delivery should aim to deliver at a health care facility fully equipped for immediate specialist delivery. This will provide access to facilities for a caesarean delivery and blood transfusion, should they be required.
Signs of a uterine rupture may include:
- an abnormal heart rate in the baby
- abdominal pain and scar tenderness in the mother
- slow progress in labour and vaginal bleeding
- rapid heart rate and low blood pressure in the mother
Appropriate care and very close monitoring of mother and baby can reduce the risk of serious consequences.
The three stages of labour typically last for 6 to 18 hours, but sometimes they may last only 3 to 5 hours. This is known as rapid labour or precipitous labour. The chances of rapid labour increase when the baby is smaller than average and there is a history of rapid labour.
Rapid labour can start with a sudden series of quick, intense contractions. This can leave little time in between for rest. They may even resemble one continuous contraction.
Disadvantages of rapid labour are that:
- it can leave the mother feeling out of control
- there may not be enough time to get to a health care facility
- it can increase the risk of tearing and/or laceration to the cervix and vagina
- haemorrhage and postpartum shock.
Risks for the baby include aspiration of amniotic fluid and a higher chance of infection if delivery takes place in an unsterile location. If there are signs of rapid labour starting, it is important to contact your hospital and call an ambulance. Lying down on your back or side may also help.
Can complications be fatal?
These complications can be life-threatening if not timely identified and managed. Worldwide, 303 000 fatalities were expected to occur every 12 months because of these complications.
Appropriate specialist health care can prevent or resolve most of these problems. It is vital to attend all prenatal visits during pregnancy, and to follow the doctor's advice and instructions regarding pregnancy and delivery.
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