Childbirth Complications

 
While every mother enters labor hoping it will be free of complications, some labors and delivieries experience obstetrical or medical complications. Most often these complications involve irregular positioning of the fetus during labor, premature birth and conditions associated with the placenta and umbilical cord. The following section will outline some of these complications and the methods used to overcome the medical obstacles created.

Fetal Position Complications

The most common variation of fetal position is the occiput posterior pose in which the head of the baby is facing the mother's abdomen. The condition is also known as back labor, due to the low back pain experienced as the baby is born in this way. Most of the time, the baby will rotate itself and deliver in the normal position, however if this does not occur, a vacuum or forceps extraction may be used. Applying gentle pressure on the lower back, changing position or using heating pads between contractions may be the best way to alleviate some of the pain associated with this form of labor.

A baby in breech presentation is not in a head-down position when it enters the birth canal. About 3-4% of babies are born in this position. There are four main types of breech positions; complete, frank, footling and transverse lie position. In a complete breech the baby's thighs are flexed against the body and the knees are bent. With the frank breech, the thighs are again flexed against the body however the legs are extended upwards towards the head. The footling breech involves an extension of the fetus with the foot dropping down to the cervix after membranes have ruptured. The transverse lie position occurs in about 1/300 pregnancies when the baby lies crosswise in the uterus. Almost always, babies in this position are delivered via cesarian section.

Prolonged Labor

Labor is prolonged when strong uterine contractions fail to expel the baby from the birth canal. Physicians pay close attention when labor is extended, to avoid maternal exhaustion and fetal distress. Labor can be prolonged if either the cervix fails to dilate or a failure of the fetus to descend into the birth canal.

To promote effacement and dilation of the cervix, the mother's physician may artificially rupture membranes and give her pitocin intravenously. If the baby fails to descend because his head is disproportionately large compared to the mother's pelvis then she may deliver through a cesarean section.

Premature Labor

Premature labor occurs when the gestation period has been less than 37 weeks. The causes in nearly half the cases are a mystery, but premature labor can be caused by an early rupturing of membranes, multiple pregnancy, preeclampsia, cervical incompetence and some abnormalities of the uterus. If the membranes rupture then there is little that can be done to delay a premature labor. However, if labor occurs between 24-34 weeks, physicians aim to delay labor so that the baby's lungs can mature. Premature labor is often easier than full-term labor, simply because the baby is smaller and the his head is softer. The mother will probably not be given inhalation analgesic drugs because they can depress the baby's respiratory system.

The following points can help diagnose pregnancies at risk for premature labor:

· the mother's pregnancy is less than 37 weeks in length.
· Uterine contractions have lasted for 30 seconds and persisting for at least one hour.
· A vaginal exam shows the mother's cervix is dilated to at least one inch and is 75% effaced.

Complications Involving the Placenta and Umbilical Cord

Placenta previa is a condition in which the placenta is attached too low to the wall of the uterus. When the cervix dilates, it can dislodge the placenta, putting both the mother and the baby at risk of serious bleeding. This condition is quite rare, occurring in only 1/200 births.

Placental abruption occurs when the placenta disconnects from the uterine wall before the baby is born. This cuts off the baby's oxygen source and the blood loss is harmful to the mother as well. Placental abruption occurs in less than 2% of all births.

If a pregnancy continues beyond 42 weeks, then an aging placenta may fail to provide the baby with adequate oxygenation and nutrition. In order to reduce the risk to the baby, physicians may induce labor that has continued one or two weeks beyond the due date.

If the umbilical cord slips out of the cervix, the baby is in danger of suffering blocked blood flow whenever the uterus undergoes a contraction. This condition is known as cord prolapse and is usually fixed by delivery via a cesarian section. This circumstance of delivery occurs in about 1/300 births.

Sudden Birth

At times, a labor can progress at such a great speed that the mother and her birthing assistant may not make it to the hospital in time. If on the way to the hospital the urge to bear down and push arises, resist this through the use of breathing and calming techniques. If the urge is too strong however, pull the car over and cover the backseat with towels or newspaper, if available.

The mother will feel the baby being born along with a burning sensation as your vagina is stretched. Keep panting and blowing so that the vagina and perineum have time to stretch without tearing. When the baby's head is born, wipe each eye from inside to outside with separate pieces of moistened cotton and feel around the neck to see if the cord is wrapped around it. If it is, gently slide the mother's finger under it and loosen it over the baby's head. Do not cut the cord under any circumstances, as this may interfere with the baby's supply of oxygen. Once the baby is born, he will probably give a good cry. If this is not the case, place him face down on your thigh with his head lower than his legs so that the mucus can drain out of him. Once he is breathing, wrap him warmly with his placenta and hold him close to the mother's body. Do not try to wash him off or cut the umbilical cord.

Induced Birth

Labor is often induced when there is concern for the health of the mother and the baby or when the baby is ready to be born and contractions have not yet begun. The following is a list of possible reasons for inducing labor:

· Labor hasn't started even after the membranes have ruptured.
· the mother and the baby are Rh incompatible.
· the baby is small for his gestational age.
· There is an infection in the mother's uterus.
· the baby is beyond 42 weeks gestation i. e. past term.
· the mother's amniotic fluid has decreased.
· the mother develops high blood pressure and preeclampsia.
· If the mother has existing medical conditions, such as kidney disease, and they create complications during pregnancy.

There are three main ways of inducing labor; through stimulation of the nipples, artificially rupturing the amniotic membranes or administering oxytocin. Nipple stimulation is the natural form of inducing labor, since it causes the hormone oxytocin to be released which in turn causes uterine contractions. An amniotomy consists of using a sterile hook to painlessly rupture the amniotic membrane so that the mother's body can produce the hormone prostaglandin which will allow contractions to progress. Finally, physicians can also administer synthetic oxytocin (known as Pitocin or Syntocinon) to help stimulate contractions.

While labor induction can seem a little frightening at first, remember that it is being done for the health of the mother and the baby. Don't hestitate to ask questions if it is difficult to understand what is going on. It is important to know why the procedure is necessary, what other options are available and the risks associated with the procedure. Remember, everyone is working to make the mother and the baby as comfortable and healthy as possible.

Cesarean Birth

If a normal vaginal birth is considered unsafe for the mother and the baby, then the mother's physician may elect to perform a cesarean section to deliver her child. About 25% of babies in the United States are delivered by this method, for various reasons. Usually if there is fetal distress, the labor fails to progress, the baby is improperly positioned, there is not enough room for the baby, the mother's health is poor, there are multiple pregnancies or an obstetrical emergency such as placental abruption.

Elective cesareans are planned ahead of time and are usually carried out because the baby is too large to pass through the birth canal or is in a breech position. An epidural anesthetic is used instead of a general anesthetic and this conveys many benefits, including increased safety for the baby, no post-operation vomiting and the ability to hold the mother's child immediately after birth because of maintained consciousness.

The risks to the mother and her child during cesarean birth are not significant, but still present. The chance of a woman dying after giving cesarean birth is 1/2 500 in comparison to 1/10 000 after vaginal delivery. The following table provides a summary of the risks to the mother and her child during a cesarean birth:

Risk to Mother	Risk to Baby
Infection of the uterus, bladder or kidneys	Premature birth
Increased blood loss (2x that of vaginal births)	Respiratory problems like abnormally fast breathing
Reduced bowel function - distention, bloating and discomfort	Low Apgar scores due to distress or anesthetic
Longer hospital stay and recovery time	Fetal injury through surgeon error
Reactions to anesthetic such as rapid blood pressure drop

Anesthesia: Regional vs. General

This section will discuss the advantages and drawbacks of using a regional anesthetic such as an epidural instead of a general anesthetic. Regional anesthetic can be applied in the form of an epidural where pain medication is delivered outside of the space surrounding the spinal cord. The pain relief lasts from 3-5 hours and takes up to 20 minutes to dispense. A spinal block is the alternate type of regional anesthetic available, in which the pain medication goes into the spinal fluid. This is a faster and easier method of administration when compared to the epidural, but it only lasts about 2 hours.

The following table will provide a list of pros and cons for using a regional anesthetic during the cesarean birth of the mother's child:

Advantages	Disadvantages
Being conscious and awake for the birth of the mother's child	The mother may still have to use a general anesthetic
The procedure is straightforward and consistent	Possible side effects include nausea and vomiting
The father of the baby or birth assistant can be present	The mother may experience a postoperative headache which can be relieved through an epidural blood patch
The baby is exposed to a negligible amount of medication
Pain relief can extend beyond the operation period

Disadvantages	Advantage
Not being awake or conscious to experience the birth of the mother's child	Can be quickly administered in emergency situations
The effects of the anesthetic may make the baby sleepy
The mother may be at a small risk of vomiting or inhaling any partially digested food in her stomach. This is why she should not eat during labor.
The mother will be more groggy and nauseated than after regional anesthesia.

The Steps of a Cesarean Delivery

Once it has been decided to have a cesarean section, the mother will be placed on an IV and have her bladder drained with a catheter. The top third of her pubic hair will also be shaved. The operating room will be a busy place, full of surgeons and nurses. If a regional anesthetic is applied, it will be done at this stage and then the mother's stomach will be washed with antiseptic soap and she will be covered with clean sheets. The mother's view of the surgery will be obscured so she do not have to watch herself being operated on.

Two incisions will be made; an abdominal one and a uterine incision. The abdominal incision goes through skin, fat and muscle and stops at the lining of the stomach known as the peritoneum. The mother may have either a vertical incision from below the navel to above the pubic bone, or a bikini incision which is a horizontal cut made near the pubic hairline. The uterine incision can either be a low transverse incision, a high vertical incision or a low vertical incision. The type of incision chosen will depend on the position of the mother's baby and the urgency of the delivery. The baby will be pulled out along with the placenta through this incision and the umbilical cord will be clamped and cut. The whole procedure, from application of the anesthetic to delivery takes about 10 minutes.

Once the baby has been delivered it's not over yet. The doctor still has to patch the mother up by sewing the uterus back together and then stiching the peritoneum. The muscle layer is tacked together and the skin is closed stiches, staples or bandage-like steristrips. This is the more time consuming part of the birth, taking approximately half an hour to 45 minutes.

Once the suturing is complete, the general anesthetic will be stopped and the mother will regain consciousness. If the mother had a regional anesthetic then she will probably be enjoying her new baby with her partner. After this the mother will be moved to a recovery room where her breathing and blood pressure will be regularly monitored.

Recovery after a Cesarean Section

The cesarean section is just like any other surgery in that the mother will need to rest after it has been completed. A common problem following cesarean sections is infection and about 20% of mothers will have a fever for a few days after giving birth. Giving antibiotics immediately after the delivery of the baby has siginificantly reduced the rate of infection in new mothers.

Many women who have had cesareans advise new mothers to ensure there is adequate support in taking care of themselves and their newborn after the surgery. Many mothers find it difficult to move around, much less feed and clean a new infant as well.

The mother may experience gas pains and constipation so she should eat lightly for the first couple of days and walk around to ease discomfort. As well, the catether in her bladder will remain there for a few hours after delivery and its removal will make urination uncomfortable at first. There may be some pain at the incision site and this will be eased by IV administration of pain medication and other fluids.

Emotionally, the mother may be feeling a little upset about having had to deliver her baby via a cesarean section. The feeling of disappointment may be intense at first, but it can be alleviated by discussing the mother's feelings with her partner, family or a community support group. Also, sharing the mother's experience with another new mother may prove to be a valuable form of therapy for her.

Vaginal Birth After Cesarean (VBAC)

It has been a common misconception among obstetricians and mothers that once one has had a Cesarean section, any other subsequent birth should also be delivered in the same manner. Usually a mother was booked for a Cesarean around 38-40 weeks gestation and the surgery was carried out without waiting for labor to begin. Physicians believed this was the best method because the uterine scar was at risk of rupturing during a vaginal birth. They also thought if a woman needed a Cesarean once she would most likely need one again. All these thoughts have now been shown to be false.

As a result of women choosing to give birth vaginally as a 'trial of labor' after a cesarean, statistics have accumulated regarding the safety of this practice. Research has found two main outcomes:

· Using a transverse lower uterine incision, trial of labor after Cesarean is safer for the mother and baby than a repeat elective Cesarean.
· With a trial of labor, over 80% of women deliver vaginally.

The probability of a successful vaginal birth is not changed considerably by the reason for the first Cesarean nor the number of previous Cesarean sections. The care offered to a woman experiencing VBAC should be no different from one undergoing a normal vaginal delivery. The same equipment, facilities, anesthetics and medications such as oxytocin can be used for a VBAC mother or a regular vaginal birth mother.

It is important to note however, that if the mother had a classical incision of the uterus in her previous Cesarean section, then there is a higher risk of uterine rupture during VBAC and an elective Cesarean section may be safer for the mother and her baby.

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