Birth complications are uncommon. The majority of births are very straightforward. But it’s important to be aware of the potential complications for both mum and baby that can arise during labour and birth.
As situations can change very rapidly, there isn’t always time to give full and detailed explanations of what the medical and midwifery teams are doing. This is why reading about this well before going into labour, coupled with taking time to discuss this along with any anxieties you may have, with your obstetrician, midwife or paediatrician is so valuable.
Don’t be alarmed or worried by the complications being covered. Most birth experiences go smoothly and without complication. That in mind, experience illustrates that where there is advance awareness for expectant parents, there is an improved opportunity for a positive birth experience for both mum and baby.
Positioning of the Baby’s Head
The streamlined position for a baby to be born is facing downwards. With the nape of the neck towards the mum’s pubic bone this is called occipito-anterior (OA). If the baby isn’t in the streamlined position, a normal birth can be more difficult or not possible at all. Occipito-posterior (OP) or “back to back” labours can be longer and cause increased back pain for the mum. An epidural may help in an OP labour.
Once the cervix is fully dilated it’s sometimes possible to gently turn the baby’s head in to the correct position. Using either gentle pressure in the vagina or using a suction cup device called a ventouse. The cup fits firmly on to the baby’s head. During a contraction and with the help of mum’s pushing, the obstetrician or midwife gently pulls to help deliver the baby. If the baby’s head still doesn’t turn, sometimes an emergency caesarean section is needed. A neonatologist (newborn paediatrician) can be contacted for support, if not already present at the birth.
Going through labour is an important part of preparing your baby for life outside the womb. The contractions help to squeeze the amniotic fluid from the air sacs in the lungs. The stress of labour helps to switch on the production of surfactant. Surfactant is the substance produced by the lungs to help the baby take their first breaths and for the lungs to fully inflate. This means that “stress” for the baby during labour is a good thing.
There are some babies that become distressed in labour which is a different situation. This is where their oxygen levels drop during contractions and they don’t tolerate this well. The signs of this are certain patterns on the foetal heart tracing (the CTG). Or green staining of the amniotic fluid because the baby has opened their bowels and passed meconium inside the womb. Meconium is the sterile bowel motions of a baby and when this occurs inside the womb, this can cause complications.
Fetal distress may also occur when the baby is small and hasn’t grown well. Or if labour has been going on for a long period of time. Occasionally, the cord is round the baby’s neck, disrupting the supply of oxygen and this can cause distress.
Depending on the stage of labour you may be asked to start active pushing. Or be recommended to have a small cut, called an episiotomy or the use of a ventouse or forceps may be needed to assist with the delivery. If the cervix isn’t fully dilated and the baby is distressed, your obstetrician may recommend an emergency caesarean section.
This is an uncommon complication of delivery where the baby’s head is born but the baby’s shoulders get stuck behind the mother’s pubic bone. The method for managing this is to bring the mother’s legs right up. Pressure is applied on her abdomen above the pubic bone. This is to rotate the baby’s shoulders, allowing the rest of the body to be born.
Bleeding in pregnancy can be due to a low-lying placenta over the cervical opening. This is known as placenta praevia, or due to separation of the placenta from the womb known as an abruption
The scan at 18-20 weeks will have shown the site of the placenta. So if the placenta is low-lying, this will have been evident at that time and the mother will have been recommended to have an elective caesarean section.
If a woman with a known low- lying placenta goes into labour before the date of her planned caesarean section, sometimes she presents with vaginal bleeding. She would then need an emergency caesarean section if she is full term (beyond 37 weeks).
Bleeding due to the placenta separating (abruption) is usually, but not always, painful. There is a considerable extra reserve in the placenta to ensure the baby has a good supply of oxygen and nutrients. But if there has been a significant separation, it is likely that an emergency caesarean section would be needed.
Some women have bleeding after the placenta is delivered, a postpartum haemorrhage. The womb should contract after the baby is born to separate the placenta and deliver the placenta, and then remain contracted to stop bleeding. Active management involves giving a hormone injection and pulling gently on the umbilical cord to deliver the placenta. If the womb doesn’t contract properly after this, the woman can bleed and may need further injections or a drip into the vein to cause the womb to contract. Occasionally, a blood transfusion may be needed. The risk of postpartum haemorrhage is three times higher if the woman opts for a natural third stage.
Sometimes the placenta doesn’t deliver with the injection. Cord traction is retained which increases the risk of postpartum haemorrhage. This might be because the cervix clamps down too quickly or because the placenta is unusually stuck to the womb. In this case the woman will need to go to theatre for removal of the placenta. This can be done under a spinal or a general anaesthetic. Once anaesthetised, the obstetrician puts their hand inside the womb and gently separates the placenta and removes it. Antibiotics and are given and a small number of women also need a blood transfusion after this procedure.
Anal Sphincter Injury
As the baby’s head passes through the vagina and pelvic floor muscles it stretches the tissues and can cause tearing. Small tears are common. They may need some stitches but this part of a woman’s body has a good blood supply so heals very quickly. Sometimes it is better to do an episiotomy, if the tissues are over-stretched and tearing. This is done at an angle towards the woman’s right buttock to avoid tearing vertically in to the anal sphincter. The anal sphincter is a circular muscle around the anus which we use to stop passing wind or motions at inconvenient moments.
Occasionally, even if an episiotomy is done, there is still damage to the sphincter muscle. This then needs very careful repair to stitch the muscle back together again. This is done in theatre, usually under a spinal anaesthetic. After the repair, antibiotics and laxatives are given to help with the healing process.
Unexpected Need for Resuscitation
Rarely a baby is born unexpectedly in need of immediate support in taking their first breaths. The labour and delivery appear to be going well but when the baby is born, its body is floppy and has a slow heart rate or not taking the first breath. If this happens the baby will be taken straight to the resuscitaire. They will be dried and stimulated and may be given oxygen or other medication. Those babies may recover or may need to be transferred to the neonatal intensive care unit for further treatment or observation. The resuscitation is led by the paediatrician, with help from the midwife at the delivery. In Cayman a paediatrician is present at all private obstetrician deliveries. They are available to be called to other deliveries, if needed.
It’s natural to have questions and concerns about the arrival of your newest family member. Having a birth plan is a great way to help the experience go smoothly. This will enable your obstetrician, midwife or paediatrician to know in advance, what you feel most comfortable with. They can work together seamlessly for you and your baby. Keeping in mind, because you cannot predict everything that may occur that day, there may need to be changes made to the plan once your labour begins. Take the opportunity now to discuss both your birth plan and potential complications. These proactive conversations will support being flexible and prepared, if something unexpected happens.