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Complications that Arise During Childbirth
Each year in the United States, millions of healthy babies are delivered in hospitals, at home, by midwives, etc. Many babies go through 38-40 weeks of gestation without causing any disruptions to their mothers except some physical characteristic changes. Then, at the time of delivery, they begin their journey on earth with relatively no excitement or trauma. However, some babies and mothers are just not that lucky. Mothers may go through their full pregnancy with prenatal care and never experience or display any signs or symptoms of what may lie ahead during childbirth. There are many different labor and delivery complications that arise even after a normal pregnancy including nuchal cord, abnormal positioning, post-partum hemorrhaging, and vasa previa.
When a mother in labor first enters in the hospital, after she is checked in much like a hotel, she will be shown to taken to a room (bed). At that point a fetal monitor will be connected to her by wrapping a belt around her belly. Various things will be monitored during this time including the mother's heart rate, baby's heart rate, and intensity and frequency of contractions. Signs and symptoms of a fetus may begin to surface at the onset of delivery. One of the first signs that may signal a baby is in distress is an abnormal heartbeat (Moldenhauer). Another sign of fetal distress may be the preterm premature rupture of membranes (PPROM). If a mother experiences any fluid leaking from the vagina before week 37, it may be a sign of ruptured membranes, but not the first stage of labor. The amniotic fluid which is the water that provides cushioning surrounding the baby is held in by these membranes. It may cause respiratory problems, umbilical cord prolapse, disrupt the placenta, or death to the fetus. The most common complication is compression of the umbilical cord because the bubble is no longer present to prevent the pressure on the cord. According to the University Of Maryland Medical Center, expectant mothers are at risk if they have sexual transmitted diseases or develop a uterine tract infection (UTI). Smoking cigarettes also puts them at risk for PROM. Other risk factors include poor nutrition or multiple babies during one pregnancy. Currently, this complication affects about 3 percent of pregnancies. If the baby's lungs are not fully developed it is important to try to delay labor through the administration of corticosteroids and antibiotics to decrease the risk of infection (Medina).
The first complication that may become alarming to a hospital staff is what is referred to as nuchal cord. Nuchal cord is when the umbilical cord has become wrapped around the baby. Most commonly, nuchal cord is referred to mean around the baby's or babies' neck. It is one of the most common labor complications occurring in about one fourth of deliveries. Most of the time there is little or no indication of nuchal cord. Some doctors are aware of it through ultrasounds, but ultrasounds are not a common procedure completed during routine checks in the latter part of pregnancies. Sometimes, during labor the doctor may be able to reach his hand up and slip it over the head during delivery. In other cases, the professional staff will opt to cut the umbilical cord after the baby's head is delivered but before the shoulders are brought out of the mother. In more extreme cases, an emergency C-section may be required if the umbilical cord is causing the baby to experience difficulty breathing during the labor process. Although it is very common, it is probably one of the least alarming complications (Moldenhauer).
During an interview with Amber Serrill, we discussed her real life experience of delivering her third son, who had nuchal cord complications during delivery. She stated that her pregnancy was completely normal up until the last day she saw her doctor on December 21st at 38 weeks 5 days. Her actual due date was not until December 30th. At her appointment on the 21st, he obstetrician stripped her membranes in hopes of causing her to go into labor. Her appointment was at 10 o'clock in the morning. Around 1p.m., Amber felt as if she might be in labor, but was not sure. Her pain level was not nearly as high as in her previous two labors with her two other sons. Around 5 p.m., she did not feel that great and was still experiencing intermittent contractions. Finally at 7 p.m. she told her husband she wanted to go to the hospital. Once at the hospital, the nurse told her the contractions were not strong enough to keep her in the hospital. The nurse then tested her glucose levels and determined that she was severely dehydrated. It was not long after that, the nurse noticed an abnormal heart rate for the baby. It seemed as if the baby was in distress during contractions due to a low heart rate. She realized that the umbilical cord was literally strangling the baby. It became imperative to deliver the baby as soon as possible. Amber was able to push the baby's head out. At that point the doctor immediately cut the umbilical cord to alleviate the constriction before delivering him completely. Amber narrowly escaped having a C-section and her baby was delivered without any further complications (Serrill).
Another complication that does not necessarily surface until the day of delivery is abnormal positioning otherwise known as breeched. For abnormal positioning, there are numerous ways a baby maybe positioned incorrectly. Abnormal positions include but are not the same as breeched, and should not be confused or interchangeable terms. For breeched babies, there is one out of five babies that are breeched. Multiple babies in the womb, low lying placentas, and incorrect amounts of amniotic fluid may also result in the baby winding up in a breech position according to the article found in Bounty. By week 36 or 37, most babies will reposition themselves correctly. If not, there is a highly controversial treatment known as external cephalic version (ECV). Bounty defines "ECV is where an obstetrician or specially-trained midwife exerts gentle pressure on your tummy to encourage your baby to do a somersault and lie in the head down position." The Royal College of Obstetricians and Gynecologists recommend that all women experiencing breeched positioned babies receive ECV. Different sources stat the amount of success this procedure, but all concur that it is very successful in repositioning the breeched baby. However, there are some advocates to this procedure that argue that it may cause additional harm to the unborn child or mother. Some complications noted are umbilical collapse and rupture of membranes too early sending the mother into premature labor (Bounty).
Another form of abnormal positioning in the womb that causes alarm during labor is shoulder dystocia, also referred to as transverse lie. It is when a baby lies horizontally with the shoulder entering the birth canal first. The baby is not able to properly enter the birth canal therefore it becomes deprived of oxygen (Moldenhauer). According to the article in American Family Physician, it occurs more frequently in babies who have higher birth weights, generally over 8 pounds 13 ounces. Shoulder dystocia can cause other complications during delivery as well. The umbilical cord may become compressed causing the baby's life line to be in jeopardy. Certain risk factors may predispose women to experience shoulder dystocia. Diabetes is a high risk factor for this during labor. In addition, the biggest risk factor for a woman to experience shoulder dystocia is the use of forceps or vacuum extraction. Expecting mothers who are overweight or obese may also be predisposed to experience shoulder dystocia. Shoulder dystocia may also cause complications after delivery to the mother and the child. The child may experience various types of birth defects. In 4 to 15 percent of infants who have shoulder dystocia, the child will experience paralysis in their arm. Most of the time, it is only a temporary paralysis and the child eventually regains use of their arm. The child may also suffer from a broken arm or shoulder during delivery. In more extreme cases lack of oxygen to the fetus or death may occur. For the mother, she may experience complications that range in levels of severity as well. The mother may have an episiotomy or a cut or tear in the vagina. The mother may also have her uterine rupture. More severe cases and trauma include rectovaginal fistula, symphyseal separation or post-partum hemorrhaging. The American Physician Family Journal recommends that the mnemonic of HELPERR be used to try to elevate shoulder dystocia. The
HELPPER stands for:
H- Call for Help,
E - Evaluate for episiotomy
L - Legs
P - Suprapubic pressure
E - Enter maneuvers (internal rotation)
R - Remove the posterior arm
R - Roll the patient
If all of these tools fail to relieve the shoulder dystocia, it is important to move quickly to perform other maneuvers to alleviate the complication.
Postpartum hemorrhaging is a serious complication that may result from childbirth. PPH is excessive bleeding with over 500mL of blood loss from the uterus after delivery. This complication is present in 18% of births and causes the most maternal deaths. This is another complication where the mother may have a completely normal pregnancy with no signs or symptoms. Due to the fact that it is an emergency situation if presented during childbirth, the birthing staff must be prepared to react in the event the mother experiences post-partum hemorrhaging. However, there are many risk factors that predispose women to post-partum hemorrhaging. A mother is at risk if she is delivering multiple babies or a baby with excessive fetal macrosomia or excessive birth weight. According to the Mayo Clinic, excessive birth weight is typically over 8 pounds 13 ounces. If the mother experiences post-partum hemorrhaging, it may cause the mother to be anemic or extremely fatigued. This makes it difficult for new mothers to care for their child after childbirth. Currently in Asia and Africa post-partum hemorrhaging accounts for a one third of maternal deaths in childbirth. According to Donald McNeil, an effective method of preventing hemorrhaging is to eliminate pulling on the umbilical cord after delivery. Other preventive treatments include massaging the uterus and administering shots of oxytocin to cause the uterus to contract after labor (Anderson).
Vasa previa is another complication that may arises during childbirth. Vasa previa occurs when the umbilical cord does not form correctly. When the blood vessels that feed the umbilical cord develop, they grow on the outside of the umbilical cord and enter into the birth canal according to the article written by Andre Picard. When the water breaks, it causes these blood vessels to rip open and cause excessive and rapid bleeding. The result could lead to either mother and/or child dying. The rate of occurrence of vasa previa is relatively low and considered a rare complication. However, it does occur and is something to be aware of and have knowledge on how to handle if it should occur. There is no concrete evidence to explain why a mother will develop vasa previa. However, physicians have identified possible risk factors that may predispose a mother to vasa previa. Some of the risk factors include a bilobed placenta or low lying placenta. Other risk factors include multiple pregnancies and in vitro fertilization. The major controversy with vasa previa deals with the detection and screening during an ultrasound. However, others argue that it is not easily detected. Andre Picard states that some obstetricians believe that vasa previa can be determined during an ultrasound with an extra two second check. He urges that mothers demand to have this screening completed, especially mothers who exhibit the known risk factors. In the article, he states that ultrasound technicians routinely scan for a condition known as placenta previa and the extra two seconds would allow the tech to also check for the vasa previa. If it is determined that vasa previa is present, a mother can eliminate the risk of losing the baby to labor complications by electing to schedule a C-section after the lungs have fully developed, usually between 36 and 37 weeks. On the flip side of these beliefs, Philip Hall writes an article that negates the statements made by Andrew Picard. He states that vasa previa is an extremely rare condition that results in fewer than 100 infant mortality cases per year. He writes that vasa previa screening requires a highly specialized trained technician to complete the screenings for vasa previa which requires far more time than the "two seconds" noted by Picard. He argues that since it is an extremely rare complication it is not cost or time effective to screen every mother for vasa previa. Nonetheless, in regards to vasa previa, knowing a C-section can eliminate any emergency situations during childbirth may put an expectant mother at ease if she does experience this complication.
There are many labor complications that may arise during childbirth after a completely normal pregnancy including nuchal cord, shoulder dystocia, post-partum hemorrhaging, and vasa previa. As an expecting mother it is important to be aware of risk factors in regards to potential complications even with a completely normal pregnancy. It is also good to be well informed about potential signs and symptoms that may trigger detection before delivery. Mothers may also want to educate themselves on the remedies and solutions that may take place should an emergency situation or complication arise during delivery. A calm, informed mother who is not alarmed and able to remain relaxed during delivery certainly helps all around. From a healthcare provider standpoint, it is important to be very educated and aware of complications that may arise and send a normal delivery into a life-threatening situation in a matter of seconds. It is important to detect signs and symptoms and implement the best solutions as quickly as possible. The most important factors during the child birthing process is to keep mother and child safe to deliver a happy baby.
