The labor and birth process is usually straightforward, but sometimes complications arise that may need immediate attention.
Complications can occur during any part of the labor process.
According to the Eunice Kennedy Shriver National Institute of Child Health and Human Development, specialized help is more likely to be needed if a pregnancy lasts more than 42 weeks, if there has been a previous cesarean delivery, or when the mother is of an older age.
This article will look at ten of the problems that can occur, why they happen, the treatment available, and some measures that can help prevent them.
1. Failure to progress
Prolonged labor, labor that does not progress, or failure to progress is when labor lasts longer than expected. Studies suggest that this affects around 8 percent of those giving birth. It can happen for a number of reasons.
The American Pregnancy Association define prolonged labor as lasting over 20 hours if it is a first delivery. For those who have previously given birth, failure to progress is when labor lasts more than 14 hours.
If prolonged labor happens during the early, or latent, phase it can be tiring but does not usually lead to complications.
However, if it happens during the active phase, medical assessment and intervention may be needed.
Causes of prolonged labor include:
- slow cervical dilations
- slow effacement
- a large baby
- a small birth canal or pelvis
- delivery of multiple babies
- emotional factors, such as worry, stress, and fear
Pain medications can also contribute by slowing or weakening uterine contractions.
If labor fails to progress, the first advice is to relax and wait. The American Pregnancy Association advise taking a walk, having a sleep, or running a warm bath.
In the later stages, health professionals may give labor-inducing medications or recommend a cesarean delivery.
2. Fetal distress
"Non-reassuring fetal status," previously known as fetal distress, is used to describe when a fetus does not appear to be doing well.
The new term is recommended by the American College of Obstetricians and Gynecologists (ACOG), because "fetal distress" is not specific, and it may result in inaccurate treatment.
Non-reassuring fetal status may be linked to:
- an irregular heartbeat in the baby
- problems with muscle tone and movement
- low levels of amniotic fluid
Underlying causes and conditions can include:
- insufficient oxygen levels
- maternal anemia
- pregnancy-induced hypertension in the mother
- intrauterine growth retardation (IUGR)
- meconium-stained amniotic fluid
It is more likely to occur in pregnancies that last 42 weeks or longer.
Strategies that may help with during episodes of non-reassuring fetal status include:
- changing the mother's position
- increasing maternal hydration
- maintaining oxygenation for the mother
- amnioinfusion, where fluid is inserted into the amniotic cavity to relieve pressure on the umbilical cord
- tocolysis, a temporary stoppage of contractions that can delay preterm labor
- intravenous hypertonic dextrose
In some cases, a cesarian delivery may be necessary.
3. Perinatal asphyxia
Perinatal asphyxia has been defined as "failing to initiate and sustain breathing at birth."
It can happen before, during or immediately after delivery, due to an inadequate supply of oxygen.
It is a non-specific term that involves a complex range of problems.
It can lead to:
- hypoxemia, or low oxygen levels
- high levels of carbon dioxide
- acidosis, or too much acid in the blood
Cardiovascular problems and organ malfunction can result.
Before delivery, symptoms may include a low heart rate and low pH levels, indicating high acidity.
At birth, there may be a low APGAR score of 0 to 3 for more than 5 minutes.
Other indications may include:
- poor skin color
- low heart rate
- weak muscle tone
- weak breathing
- meconium-stained amniotic fluid
Treatment of perinatal asphyxia can include providing oxygen to the mother, or carrying out a cesarean delivery.
After delivery, mechanical breathing or medication may be necessary.
4. Shoulder dystocia
Shoulder dystocia is when the head is delivered vaginally but the shoulders remain inside the mother.
Health providers may apply specific maneuvers to release the shoulders:
- changing the mother's position
- manually turning the baby's shoulders
An episiotomy, or surgical widening of the vagina, may be needed to make room for the shoulders.
Complications are usually treatable and temporary. However, if a non-reassuring fetal heart rate is also present, this may indicate other problems.
Possible problems include:
- fetal brachial plexus injury, a nerve injury that may affect the shoulder, arms, and hand but usually heals in time
- fetal fracture, in which the humerus or collar-bone break, which usually heal without problems
- hypoxic-ischemic brain injury, or a low oxygen supply to the brain, which can, in rare cases, be life-threatening or lead to brain damage
Maternal complications include uterine, vaginal, cervical or rectal tearing and heavy bleeding after delivery.
5. Excessive bleeding
On average, women lose 500 milliliters (ml) of blood during the vaginal delivery of a single baby. During a cesarian delivery for a single baby, the average amount of blood lost is 1,000 ml.
It can occur within 24 hours after delivery or up to 12 weeks later, in the case of secondary bleeding.
Around 80 percent of cases of postpartum hemorrhage result from a lack of uterine tone.
Bleeding happens after the placenta is expelled, because the uterine contractions are too weak and cannot provide enough compression to the blood vessels at the site of where the placenta was attached to the uterus.
Low blood pressure, organ failure, shock, and death can result.
Certain medical conditions and treatments can increase the risk of developing postpartum hemorrhage:
- placental abruption or placenta previa
- uterine overdistention
- multiple gestation pregnancy
- pregnancy-induced hypertension
- several prior births
- prolonged labor
- the use of forceps or a vacuum-assisted delivery
- use of general anesthesia or medications to induce or stop labor
Other medical conditions that can lead to a higher risk include:
- cervical, vaginal or uterine blood vessel tears
- hematoma of the vulva, vagina or pelvis
- blood clotting disorders
- placenta accreta, increta, or percreta
- uterine rupture
Treatment aims to stop the bleeding as soon as possible.
- the use of medication
- uterine massage
- removal of retained placenta
- uterine packing
- tying off bleeding blood vessels
- surgery, possible a laparotomy, to find the cause of the bleeding, or hysterectomy, to remove the uterus
Excessive bleeding can be life-threatening, but with rapid and appropriate medical help, the outlook is normally good.
Not all babies will be in the best position for vaginal delivery. Facing downward is the most common fetal birth position, but babies can be in other positions.
- facing upward
- breech, either buttocks first (frank breech) or feet first (complete breech)
- lying sideways, horizontally across the uterus instead of vertically
Depending on the position of the baby and the situation, it may be necessary to:
- manually change the fetal position
- use forceps
- carry out an episiotomy, to surgically enlarge the opening
- perform a cesarian delivery
Problems with the umbilical cord include:
- become wrapped around the baby
- getting compressed
- emerging before the baby
If it is wrapped around the neck, if it is compressed, or emerges before the baby does, medical help will probably be needed.
7. Placenta previa
When the placenta covers the opening of the cervix, this is referred to as placenta previa. A cesarian delivery is usually necessary.
It affects around 1 in 200 pregnancies in the third trimester.
It is most likely to occur in those who:
- have had previous deliveries, and especially four or more pregnancies
- previous placenta previa, cesarean delivery, or uterine surgery
- have a multiple gestation pregnancy
- are aged over 35 years
- have fibroids
The main symptom is bleeding without pain during the third trimester. This can range from light to heavy.
Other possible indications include:
- early contractions
- the baby being in breech position
- a large uterus size for the stage of pregnancy
Treatment is usually:
- bed rest or supervised rest in the hospital, in severe cases
- blood transfusion
- immediate cesarean delivery, if the bleeding does not stop or if the fetal heart reading is non-reassuring
It can increase the risk of a condition known as placenta accreta, a potentially life-threatening condition in which the placenta becomes inseparable from the wall of the uterus.
The doctor may recommend avoiding intercourse, limiting travel, and avoiding pelvic examinations.
8. Cephalopelvic disproportion
Cephalopelvic disproportion (CPD) is when a baby's head is unable to fit through the mother's pelvis.
According to the American College of Nurse Midwives, cephalopelvic disproportion occurs in 1 in 250 pregnancies.
This can happen if:
- the baby is large or has a large head size
- the baby is in an unsual position
- the mother's pelvis is small or has an unusual shape
A cesarian delivery will normally be necessary.
9. Uterine rupture
If someone has previously had a cesarian delivery, there is a small chance that the scar could open during future labor.
If this happens, the baby may be at risk of oxygen deprivation and a cesarian delivery may be necessary. The mother may be at risk of excessive bleeding.
Apart from a previous cesarean delivery, other possible risk factors include:
- the induction of labor
- the size of the baby
- maternal age of 35 years or more
- the use of instruments in vaginal delivery
Women who plan for a vaginal birth after previously having a cesarian delivery should aim to deliver at a health care facility. This will provide access to facilities for a cesarean delivery and blood transfusion, should they be needed.
Signs of a uterine rupture include:
- an abnormal heart rate in the baby
- abdominal pain and scar tenderness in the mother
- slow progress in labor
- vaginal bleeding
- rapid heart rate and low blood pressure in the mother
Appropriate care and monitoring can reduce the risk of serious consequences.
10. Rapid labor
Together, the three stages of labor typically last for 6 to18 hours, but sometimes it lasts only 3 to 5 hours.
This is known as rapid labor or precipitous labor.
The chances of rapid labor are increased when:
- the baby is smaller than average
- the uterus contracts efficiently and strongly
- the birth canal is compliant
- there is a history of rapid labor
Rapid labor can start with a sudden series of quick, intense contractions. This can leave little time in between for rest. They may resemble one continuous contraction.
Disadvantages of rapid labor are that:
- it can leave the mother feeling out of control
- there may not be enough time to get to a health care facility
- it can increase the risk of tearing and laceration to the cervix and vagina, hemorrhage, and postpartum shock
Risks for the baby include:
- aspiration of amniotic fluid
- a higher chance of infection if delivery takes place in an unsterile location
If there are signs of rapid labor starting, it is important to:
- contact a doctor or midwife.
- use breathing techniques and calming thoughts to feel more in control
- remaining in a sterile place
Lying down on the back or side may help.
Can complications be fatal?
Complications during can be life-threatening in parts of the world where there is a lack of proper health care.
Worldwide, 303,000 fatalities were expected to occur in 2015, according to the World Health Organization (WHO).
In the U.S., the figure is around 700 each year.
The main causes are:
- unsafe termination
- eclampsia, leading to high blood pressure and seizures
- pregnancy complications that worsen at the time of delivery
Appropriate health care can prevent or resolve most of these problems.
It is vital to attend all prenatal visits during pregnancy, and to follow the doctor's advice and instructions regarding pregnancy and delivery.