There are several labor and delivery complications, most resulting in a delay in normal labor progression. An abnormally prolonged labour is very trying for the mother and may be dangerous for the. For this reason, modern obstetrics pays great attention to assessing progress. If steady progress is being made and both mother and fetus are well, no action is needed. If progress is poor, careful assessment will be made by the obstetrician to decide why the delay is occurring and what needs to be done.
Delay is most often due to poor uterine contractions. If this is so andrip will be started to try to improve matters. If this does not work, or is considered inadvisable because the baby is too big to pass through the mother’s pelvis, a Caesarean section will be necessary. Delay in the second stage of labour may need forceps’ delivery or Ventouse extraction.
The normal presentation of a baby at birth is called a vertex presentation. The position of the head is quite difficult to determine, but by feeling the join between the two main bones of the fetal skull, this can usually be done. Sometimes when the fetal head is in the occipito posterior position, i.e. facing forwards, the baby is born this way, face to pubis. Sometimes, too, in this position or in the transverse position, the head is held up and can only be born with the assistance of forceps or Ventouse method.
Before applying the forceps, the obstetrician will have to turn the head the right way around. He may do this with his hand, which is known as manual rotation, or with special forceps, known as forceps rotation. As rotation is uncomfortable for the mother, either a local anaesthetic, or an epidural block, or on rare occasions, a general anaesthetic, is needed before it can be attempted. The manoeuvre can only be carried out when the cervix is fully dilated and the fetus ready to be born.
Malpresentation is when some part of the baby, other than the head, presents. The commonest and most important malpresentation is a breech presentation. Labour progresses normally with a breech presentation, but care is needed during the second stage when the arms and the after coming head are being delivered. Forceps will often be used for the head and local anaesthetic or an epidural block is essential. On rare occasions, a general anaesthetic is needed.
During labour the fetus may suffer from lack of oxygen. This happens when the contractions of the uterus squeeze the blood vessels to the placenta so tightly that they are unable to carry enough oxygen-rich blood and the fetus suffers. In normal circumstances, any deficiency in oxygen supply is quickly made up when the uterus relaxes between contractions and the blood vessels open up again. Sometimes, however, this does not occur to a sufficient extent and then the lack of oxygen causes fetal distress.
Diagnosis is made by listening to the fetal heart or by looking at the trace made by the fetal heart monitor. When fetal distress is present, the fetal heart becomes abnormally slow, or sometimes abnormally fast, and irregular. Characteristic changes are seen on the fetal heart trace and if a fetal scalp blood sample is taken, it shows a high acidity which means a low oxygen content.
Sometimes a distressed fetus passes meconium from its bowel into the amniotic sac and stains the amniotic fluid. Meconium staining of the fluid is not invariably a sign of fetal distress, but its appearance warns the obstetrician to be extra vigilant.
If fetal distress is diagnosed, the fetus must be delivered as quickly as possible. This may mean an emergency Caesarean section; or if the cervix is fully dilated a forceps’ delivery. Fortunately, in the great majority of cases, the diagnosis is made early and the baby, once delivered, does not suffer from any permanent disability.
Modern obstetric forceps are light and designed to fit snugly around the baby’s head. The use of forceps allows the doctor to gently lift out a baby who has failed to be born normally. This may arise either because the uterine contractions are not strong enough or because the mother cannot push sufficiently hard at the right moment to deliver her baby. Sometimes when fetal distress develops, delivery has to be speeded up and, in this situation, forceps are used to save the baby from suffering unnecessarily. Forceps can only be applied in the second stage of labour when the cervix is fully dilated and when there is adequate room for the baby to be born through the vagina. Local anaesthesia is essential. On rare occasions a general anaesthetic is necessary.
When forceps are used, the perineum is likely to be stretched more than usual, so an episiotomy is often needed to prevent the skin tearing. Because the forceps’ blades fit closely around the baby’s head to protect it during delivery, red marks where the blades make contact, often appear on the baby’s face. These marks, and the occasional mild bruising of the face which often results from forceps’ delivery, quickly fade and usually disappear completely forty-eight to seventy-two hours after the birth. Forceps’ delivery is more common in women having a first baby and in women who have an epidural block. If complications develop any woman may need forceps.
VACUUM EXTRACTION – VENTOUSE
Vacuum extraction (Ventouse) is an alternative to forceps’ delivery and is a means of assisting the delivery when the mother’s efforts fail to achieve it. A small metal suction cap, attached to a pump, is applied to the baby’s head. By drawing the suction cap gently downwards, the baby’s head can now be delivered through the entrance to the vagina and the delivery thereafter completed normally.
The vacuum extraction is much favoured in some maternity units and, indeed, in some European hospitals it has completely replaced forceps. It does, however, have one slight disadvantage in that the application of the suction cup to the baby’s scalp produces a localized circular bruise. This is a little unsightly to start with, but it quickly fades within forty-eight hours of delivery. Like forceps, the vacuum extractor is only used during the second stage of labour to help complete the delivery after the cervix has become fully dilated.
POST-PARTUM HAEMORRHAGE AND RETAINED PLACENTA
The third stage of labour, during which the placenta is delivered, can occasionally cause problems. Usually, as soon as the baby is born, the uterus contracts, separates the placenta from its attachment and pushes it down through the cervix into the upper part of the vagina from which it can be easily delivered.
This contraction is important because when the placenta separates it leaves a raw surface in the uterus from which bleeding, sometimes severe, can occur. A strong contraction will, however, squeeze the blood vessels shut and stop the bleeding. If the contraction is not strong enough to control the bleeding, the doctor will take immediate steps to deliver the placenta manually and will then give a further injection into a vein in the arm. Occasion ally a blood transfusion is needed. The danger of post-partum haemorrhage is well-recognized by doctors and midwives. They will quickly give the correct treatment since, in this situation, speedy action is needed to stop too much blood being lost.
Caesarean section is the extraction of the baby through an incision that is made through the mother’s abdomen and into the uterus. It is either decided for medical reasons before the onset of labour or as an emergency procedure during the course of labour. A woman, for example, with a small pelvis and a big baby or a woman with a severe degree of placenta praevia would be likely cases for a pre-decided Caesarean section. Fetal distress in the first stage of labour, or a failure to progress towards vaginal delivery after a reasonable period of time, are typical indications for emergency Caesarean sections.
Caesarean section is almost always performed under a general anaesthetic in an operating theatre. Local anaesthetic blocks are occasionally used, but are not favoured because the operation is made more difficult and the woman might suffer more discomfort. The incision is made across the lower part of the abdomen, just above the pubis (below the bikini line!). The incision in the uterus is made into its lowest part, which explains why the operation is called “lower segment Caesarean section”.
In the classical ‘upper segment’ operation, the incision is made into the upper part of the uterus, but this procedure is only rarely employed nowadays. The baby is delivered through the incision and the placenta is then removed before sewing up the uterus and the abdominal wall. The operation usually takes about forty minutes, from start to finish, and the mother should be awake and able to hear the good news about her baby almost as soon as the final stitches are put in.
Apart from the discomfort of the incision, a mother who has had a Caesarean section can expect to recover from the birth of her baby in the same way as a mother who has had a vaginal delivery. She will, however, stay in hospital a little longer – for about seven to ten days – and will have the skin stitches or clips removed about six days after the operation. The skin incision usually heals very well, only leaving an unobtrusive scar. A woman who has had one Caesarean may need to be delivered this way in subsequent pregnancies. In many cases, however, normal delivery after a previous Caesarean section will be perfectly possible and safe.