Labor Complications And Childbirth.
Labor complications and childbirth is a striking aspect in the medical field. Delivery and labor are normal biological functions which usually occur without any complications; although there may be physical or mechanical difficulties if a fetus is large, if there is a disproportion between the fetus and the mother’s pelvis or in feet-first or transverse positions.
There may also be functional difficulties resulting from maternal organic problems which disturb the normal labor process resulting to labor complications and childbirth: general weakness, problems with the uterus or other pathological difficulties.
At other times, birth can be complicated by physical accidents such as uterine, cervical, vaginal or perineal rupture or in case of pathological disorders such as hemorrhages occurring during or after labor and childbirth.
Medical Care (for labor complications).
Under certain circumstances (under specific labor complications) the obstetrician will decide to act. Medical intervention may be physical or drug-based.
- Drug therapy:- powerful drugs such as oxytocin, can be used to accelerate labor or stop any hemorrhaging.
- Physical intervention (minor) :- There are various types of minor medical intervention which can help to solve problems such as injury to the birth canal or perineum; although sometimes major intervention becomes necessary in order to save the life of the fetus, the mother, or of both.
- Physical intervention( major) :- The typical major intervention is the cesarean section. This is performed in cases of fetal distress, if vaginal birth is impossible or for a variety of other reasons, for example, if there is placenta abruptia or an abnormal insertion of the placenta with risks to mother and child.
There are other forms of intervention, such as instrumental extraction of the fetus, either through the use of forceps, spatulas or suction extractors changing the presentation by internal or external version, which requires special skill by the person assisting at the birth.
Due to the fact that complications caused by physical or physiological problems lead inevitably to pharmaceutical and surgical intervention, we have chosen to address all such complications and their corresponding treatments together in the same chapter.
We are only going to touch on the most common problems. we will try to give enough general information so that the reader can understand the problems and the solutions.
Brief Conceptual History on the Cesarean.
Egypt and Israel.
From the days of labor complications.
The cesarean delivery is mentioned in the papyrus records of ancient Egypt and in the Hebrew Talmud.
It is interesting to note that the Talmud does nor require women who have given birth abdominally to go through ritual purification.
In the Lex Regius from the second Roman emperor Numa Pompilius, there was a law ordering that an abdominal incision be made on all dead women who were full-term in an attempt to save the infant. This law as legendary as the emperor who proposed it and it came to be known as the Lex Cesarean during the reign of the Ceasars; this is where the name “Cesarean” seems to have been coined.
There is no historical evidence to support the belief, which is commonly held, that the name of the operation comes from the fact that Julius Ceasar was born in this way.
Among the Romans, a cesarean was only performed on dead or dying women. For many centuries, performing this operation meant certain death for the mother. Julius Ceasar’s mother lived years after his birth.
Until 1878 in the united states only 80 cesarean deliveries were recorded; of these, only half of the women survived. The other half died, mostly from infection.
Obstretic Operations and Procedures
A cesarean section is an operation which is performed in order to remove the fetus abdominally if vaginal birth is either impossible or risky.
The surgeon makes an incision in the abdominal and uterine walls.
This Operation which has been performed throughout the ages has saved and continues to save many lives, both those of women and children.
From the end of the 19th century (see 19th century from the cesarean history above) things have changed a great deal. Today a cesarean is performed often and there is little risk. This is due to the great advances of surgical techniques, of asepsis (absence of infection) and of antisepsis (fight against infection) along with anesthesia.
Today, cesarean sections are performed often sometimes too often.
But There Are Risks.
We should not minimized the risks which come with a cesarean section. Along with the risks which come with any operation ( embolism, infection, tearing of the stitches, fistulas, etc.) are added the risks of this particular operation which are hemorrhages and damage to the bladder.
INDUCTION AND ACTIVATION OF CHILDREN.
Often, labor proceeds slowly or abnormally;- weak contractions, few or irregular contractions. Even if labor is proceeding normally, there are times when the person assisting the birth will decide that it must be sped up or regularized. There are a number of ways of achieving this and we are going to look at two of them.
- Prostaglandins. The complex group of non-hormonal substances known as prostaglandins was discovered by Von Euler and Goldbat in the seminal liquid of men in the 1930s. Later Pickles also discovered it in the menstrual fluid. Currently, it is used to induce labor. It is placed in the vagina in the form of a gel. Prostaglandins are also effective if given orally or intramuscularly. These substances have proven to be oxytocic drugs or stimulants which cause the uterine muscles to contract.
- Oxytocin: It is a substance produced in the posterior lobe of the hypophysis. It makes the uterine fibers contract. it is used to induce labor, to activate labor, to regulate it or to shorten it. I t is also used to prevent hemorrhaging. It also helps the doctor determine much more quickly whether or not the birth can go ahead naturally or whether surgery will be needed. Thanks to oxytocin, which can reduce, accelerate or regularize the uterine contractions, many forceps procedures and cesarean sections can be avoided and quick controlled labors can be achieved.
Oxytocin is administered intravenously through a simple drip or through an infusion pump (a device which administers constant levels of the substance and can be programmed).
EXTERNAL AND INTERNAL VERSION
This is a procedure which attempts to turn the fetus around into the proper birth position.
The procedure can be done during pregnancy by the obstetrician in the office if the baby’s head is not facing downwards. The obstetrician maneuvers the fetus into the correct position by applying pressure to the mother’s abdomen.
This method is used to turn breech babies around so that they present themselves head first.
In the Case of Twins. (Serious labor complications)
In the case of twins, once the fetus has been born, if the second fetus is in a transverse position, the obstetrician can attempt an “internal version” or “combination version” (that is internal and external at the same time).
The internal version is only used in this instance. The obstetrician performs the procedure by introducing the hand inside the uterus.
Disorders of the Uterus and its Functioning
Disorders in the functioning of the uterine muscles during labor and childbirth are included here. These dysfunctions can be various types:
There is hypodynamia is the frequency and/or the intensity of the contractions diminish.
Hypodynamia implies that, labor is not strong enough to produce cervical dilation and the birth of the fetus. This causes labor to be prolonged.
Causes of Hypodynamia.
Most times, the cause is unknown. but sometimes it is due to uterine exhaustion which is caused by a prolonged but unsuccessful labor resulting from cephalopelvic disproportion (scroll down to see more about this)
The opposite disorder is called hyperdynamia.
Hyperdynamia is an increase in the uterine contractions. This increase can be in frequency and/or intensity.
Causes and Effects of Hyperdynamia.
Hyperdynamia can be natural or, as in the case of hypodynamia, it can be caused by cephalopelvic disproportion. In such an instance, the uterus is attempting to solve the problem by working harder.
Hyperdynamia can also be caused by excessive medication.
Today, this is very common and is due to the manipulation of birth labors which are induced so as to fall on a specific date and at a specific time.
In such cases (labor complications), the medication must be suspended and the patient should lie down on her side. This will help to decrease the tone and frequency of the contractions and will increase their intensity and regularity.
As in hypodynamia, it leads to prolonged labor. Excessive contractions or excessively-strong ones lead to an imbalance which causes the labor to proceed abnormally.
- Muscular tone. Sometimes uterine dysfunction occurs because of disorders in the muscle tone. Muscular hypertonia can cause fetal distress.
- In-coordination. There may sometimes be a lack of coordination in the uterine contractions, or they may occur in reverse order, that is, instead of moving from the fundus of the uterus up to the isthmus, they arise from the lower segment and impede fetal progression.
- Resistant Cervix. There are cases in which the cervix itself is the cause of the problem. For unknown reasons or because of previous damage which has caused fibrous scarring, the cervix refuses to dilate; this may happen even when the uterus is performing normally.
Treatment Hypodynamia and Hyperdynamia.
When the dysfunction is due to cephalopelvic disproportion, a cesarean section will need to be performed.
If hypodynamia is not caused by cephalopelvic disproportion, oxytocin is administered. This hormone helps to regulate the uterine contractions. Other oxytocic drugs, or drugs which stimulate the the uterine muscles such as cardiotonics or prostaglandins may also be used in reducing or solving such labor complications.
The treatment of hyperdynamia will be determined in each case by the obstetrician and his identification of the cause.
The treatment of any other dysfunction mentioned on this page (muscular tone, in-coordination, constriction and resistant cervix) will be determined exclusively by the obstetrician; but psychological support and calmness are essential since one of the causes of in-coordination is nervous excitement and anxiety on the part of the mother.
Now, lets look at…
Fetal Distress is caused by a disorder in the acid-base status due to a reduction in oxygen. It can cause serious damage to the fetal nervous system and can even lead to death. It is therefore, important to diagnose and treat fetal distress as quickly as possible.
The causes for fetal distress may originate with the mother, the placenta or the fetus itself.
For example, a sudden drop in the mother’s blood pressure can cause fetal distress.
The aging placenta or a placenta which detaches prematurely also restricts the amount of nutrients and oxygen being passed to the fetus.
One form of fetal problem (also labor complication problem) may be when the umbilical cord becomes knotted or there is umbilical cord prolapse.
A diagnosis of fetal distress is made in various ways:
- Visualization, through an amnioscope, of the amniotic liquid to see if it tinted with meconium (fetal feces)
- Breaking of the sac of waters and testing for the presence of meconium in the amniotic liquid.
- Bradycardia, or a decrease in the fetal heart beat. This decrease may occur spontaneously or may be caused by uterine contractions
- Determination of the fetal acid-base balance (pH and concentration of O2 and CO2) through a fetal blood analysis obtained from the fetal scalp
These symptoms are summarized in an old obstetric saying:
“Bradycardia and meconium from the devil come.”
This saying indicates just how serious these symptoms are.
Cephalopelvic disproportion occurs when the size or position of the fetus’s head is larger proportionally than the birth canal, thus making passage impossible.
The birth canal may be altered structurally or in form, or a normal fetus may adopt an abnormal position which requires an opening far larger than normal.
Cephalopelvic disproportion is easily diagnosed in cases of major pelvic malformations. These cases are now rare.
It may be suspected in various cases: large fetuses, women who have had rachitism, women who have had a fractured pelvis, women who are short, or women who suffer from vertebral or foot abnormalities.
The doctor will also suspect cephalopelvic disproportion when a woman has had cesarean births without apparent reasons or when she has had hard labors or stillbirths or children with permanent injuries.
The solution for cases of cephalopelvic disproportion is to perform a cesarean section.
Tearing Of The Birth Canal.
In this section, we will be referring to injuries to the soft birth canal. The most important injuries occur with hemorrhaging before or after the placenta has been born.( serious labor complications)
The problem can be;
- Injuries to the cervix due to previous scarring or too rapid births.
- Tearing of the Vagina, which may be caused by a large fetus, by a rapid birth, by a weakening of the organ, or by the improper use of surgical instruments inserted to extract the fetus.
- Tearing of the vulva or the perineum, either occuring naturally or caused by the extension of an episiotomy with the eventual breaking of the anal sphincter and of the rectum.
All tears must be identified and stitched in order to avoid hemorrhaging and later complications such as: cervical disorders which can cause later miscarriages: rectal or genital fistulas, with the leaking of urine or feces; coital dysfunction; and genital prolapse.
The Uterus is where the fetus grows. Rupture of this organ occurs when part of the uterine wall is torn. Depending on where the tear occurs, there may be few visible symptoms; but it is a serious condition which can lead to the death of the fetus, the mother or both.
There are various factors which contribute to uterine rupture: labor complications.
- Uterine scarring due to previous problems
- Prolonged labor
- Large fetuses.
The causes of this accident may be classified in the following categories: caphalopelvic disproportion, hyperdynamia, and mechanical or surgical trauma.
Symptoms and effects.
When the uterus is ruptured, the pregnant woman experiences intense pain in the area of the tear. This pain is intensified if the abdomen is touched. The abdomen seems to be contracted.
There is a sudden interruption in uterine dynamics.
There is trend to be vaginal hemorrhaging and depending on the severity of the bleeding, it can lead to hypovolemia or shock (sudden decrease in the volume of blood).
A uterine rupture also causes fetal distress because of the mother’s lowered blood pressure which causes a decrease in the amount of blood being supplied to the placenta.
Complete rupture of the Uterus.
In extreme cases which are thankfully very rare today because of the increased care given to pregnant women, the fetus remains trapped in the abdominal cavity of its mother and can be touched through the abdominal wall.
Complete uterine rupture almost always causes fetal death.
The treatment must be surgical, and it must be undertaken immediately. The fetus must be removed. Depending on the size of the tear, the surgeon will stitch it up or will perform a hysterectomy (removal of the uterus).
Problems During Third-stage Labor (Labor Problems)
Remember that labor is made up of three stages: cervical dilation, birth of the fetus and birth of the placenta.
The problems of third-stage labor are usually related to hemorrhaging.
Hemorrhaging occurs when the blood loss rises above 500 ml (half a litter), and when it occurs immediately after labor or within the first 24 hours of delivering the placenta.
Causes of Postpartum Hemorrhaging
The most frequent causes of postpartum hemorrhaging are:
- Traction of the cord
- Violent pressure on the uterus through the abdominal wall
- Incomplete detachment of the placenta, caused by pathological adherence or insertion abnormalities
- Uterine inertia (collapse of the uterus due to the abusive use of oxytocic drugs or to a prolonged labor)
- Overdistension or stretching of the uterus (gigantism, giving birth to twins, polyhydramnios)
- General anesthesia
- General unhealthy state (obesity, diabetes, cardiopathy, etc.)
- Coagulation disorders
Symptoms of Hemorrhaging
Hemorrhaging is recognized by the blood which emerges from the vulva, by the size and softness of the uterus (it should be hard and small) and by the poor state of the woman (anxiety, paleness, drowsiness, tachycardia, etc.).
Coagulation disorders may be caused by various factors:
- Intrauterine fetal death.
- Premature detachment of the placenta
- Embolism of amniotic liquid due to the passage of maternal blood
- Traumatic manipulation of the uterus.
- Hypertensive state of pregnancy
- Placenta previa
Fortunately these disorders, which are very serious and equally difficult to treat, are uncommon.
Watchfulness During Postpartum
During the third stage of labor, when the family and the medical team are happy, and they are celebrating the arrival of a new baby, serious and unpleasant surprises can occur which can at times be tragic.
If the uterus does not shrink and contract, a hemorrhage can occur and the blood loss can be considerable.
Thus, immediate postpartum must be carefully monitored especially during the first two hours or three hours.
Uterine inversion is when the uterus turns itself out, as happens with a sock; in this way the internal walls of the uterus face outwards and the external walls are inwards.
It is a serious situation and caused by incorrect methods of trying to remove the placenta often by pulling on the umbilical cord. This should never be done.
It can be accompanied by shock and hemorrhaging.
Placenta inarceration and returning of the pieces of placenta.
Other circumstances, such as the retention of parts of the placenta, adherent placenta or placental inarceration, lower insertion of the placenta or large uterine tumors can also cause hemorrhaging during third stage labor.
Curettage of the Uterus.
A curettage consists of the surgical scarping of the uterine walls to free any placental pieces which may remain and cause hemorrhaging.
Before ultrasound, the technique could cause greater Hemorrhaging and often result in a hysterectomy (removal of the uterus).
Now that there is Ultrasound equipment available, the cause of the hemorrhage can be identified and can often be controlled with drugs thus avoiding a curettage with all the inherent risks.
Treatment and Prevention of Hemorrhages.
Prevention lies in the use of correct procedures during labor and birth. The physiology of third-stage labor should be respected; the mother should be monitored and any small problems should be addressed immediately when they occur, either during birth of afterwards.
The Treatment consists in verifying the emptiness of the uterus and working to make sure that it contracts as it should. It also consists of giving blood transfusions to replace the blood which is being lost through the hemorrhaging.