Mayo Clinic Guide to a Healthy Pregnancy: From Doctors Who Are Parents, Too!

CHAPTER 28. Problems of labor and childbirth

Even if you’re doing everything right as you go through labor and childbirth, complications can occur. If something does go wrong, trust that your care provider and your health care team will do the best for both you and your baby. When complications arise and things don’t go as planned, it’s easy to feel out of control, but be as flexible as you can and try not to panic. Your care provider can explain possible concerns and discuss possible outcomes and new courses of action. Together, you can decide what the next steps should be for both you and your baby.

LABOR THAT FAILS TO START

Sometimes, labor won’t start on its own. If this happens to you, your care provider may decide to start (induce) your labor through medical intervention.

Your care provider may recommend labor induction if your baby is ready to be born but contractions haven’t started yet or if there’s concern for the health of you or your baby. Some situations in which you may be induced include:

 Your baby is overdue. You’re at or approaching 42 weeks of pregnancy.

 Your water has broken (membranes have ruptured), but your labor hasn’t started.

 There’s an infection in your uterus.

 Your care provider is concerned that your baby is no longer thriving because your baby’s growth has stopped, the baby isn’t active enough or there’s a decreased amount of amniotic fluid.

 You have health complications, such as high blood pressure or diabetes that may put you or your baby at risk.

 You have rhesus (Rh) factor complications, which means that your blood and that of your child may not be compatible.

If you were hoping for labor to begin on its own but your care provider needs to induce labor, try to view it as a positive. Making an appointment to have your baby can be more convenient than waiting for nature to take its course. Induction may allow you to be more prepared, mentally and physically, when you go to the hospital.

Inducing labor Your care provider can induce labor in several ways, but your cervix must be softening, thinning (effacing) and opening (dilating). If it isn’t doing so, your care provider may take steps to try to get things started.

Medications Medications can be used to soften and dilate your cervix. Misoprostol (Cytotec) is one such drug. Dinoprostone (Cervidil, Prepidil) is another. These drugs often work to begin labor as well, and they may reduce the need for other labor-inducing agents, such as oxytocin (Pitocin). If you need to have your cervix ripened, you may go to the hospital the night before your labor is induced to give the medication time to work.

Mechanical techniques One technique is to place a small catheter with a water-filled balloon through the cervix into the uterus. The uterus is irritated by the balloon and gradually expels it through the cervix, softening and opening it 2 to 4 centimeters (cm).

Breaking your water When your water breaks, the amniotic sac that envelops your baby tears and the fluid begins to flow out. Normally, this signals that delivery of the baby will happen fairly soon. One of the results of this rupture is increased uterine contractions.

One way to induce or accelerate labor is to artificially rupture the amniotic sac. To do this, your care provider inserts a long, thin plastic hook through the cervix and creates a small tear in the membranes. This procedure will feel just like a vaginal exam, and you’ll probably sense the warm fluid flowing out. It isn’t harmful or painful to you or your baby.

Oxytocin A common method for inducing labor is with a drug called oxytocin (Pitocin, Syntocinon) which is a synthetic version of the hormone oxytocin. Your body normally produces low levels of oxytocin throughout pregnancy. The levels rise in active labor.

Oxytocin is generally administered intravenously after your cervix is dilated somewhat and thinned (effaced). An intravenous (IV) catheter is inserted into a vein in your arm or on the back of your hand. A pump is connected to your IV that delivers small, regulated doses of the drug into your bloodstream. These doses may be adjusted throughout your induction to change the strength and frequency of your contractions until they’re occurring regularly. You should start to feel contractions after 30 minutes if the dose is adequate. The contractions may be more regular and stronger than those with a naturally occurring labor.

Oxytocin is one of the most commonly used drugs in the United States. It can initiate labor that may not have started otherwise, and it can also speed things up if contractions stall in the middle of labor and progress isn’t being made. Uterine contractions and your baby’s heart rate are monitored closely to reduce the risk of complications.

If labor induction is successful, you’ll begin to experience signs of active, progressive labor, such as longer lasting contractions that are stronger and more frequent, dilation of your cervix, and rupture of your amniotic sac — if it hasn’t broken or been broken already.

Induction of labor should be done only for good medical reasons. If your health or your baby’s is in question, your care provider may decide to take further intervention, such as a cesarean delivery. Also, induction can take many hours, especially for a first-time mom.

LABOR THAT FAILS TO PROGRESS

If your labor isn’t progressing as it should, a condition called dystocia, it’s usually due to a problem with one or more components of the birth process. Progress in labor is measured by how well your cervix opens (dilates) and the descent of your baby through the pelvis. This requires the following:

 Regular and strong contractions

 A baby that can fit through the mother’s pelvis and is in the correct position for descent

 A pelvis that’s roomy enough to allow for the passage of the baby

If your contractions aren’t forceful enough to open the cervix, you may be given medication to make your uterus contract. Contractions can sometimes start regularly but then stop halfway through your labor. If this happens and the progress of your labor halts for a few hours, your care provider may suggest breaking your water, if it hasn’t already broken, or artificially stimulating your labor with oxytocin (Pitocin, Syntocinon).

Problems that can occur during labor include:

Prolonged early labor This occurs when your cervix doesn’t dilate to 3 cm despite regular contractions — after about 20 hours of labor if you’re a first-time mother, or after 14 hours if you’ve delivered before.

Sometimes, progress is slow because you’re not in true labor. The contractions you feel are those of false labor (Braxton Hicks contractions), and they’re not effective at opening your cervix. Certain medications for pain relief given during labor can have the unintended consequence of slowing down labor, especially if they’re given too early.

Treatment Whatever the cause, if your cervix is still fairly closed when you arrive at the hospital or birthing center and your contractions aren’t very strong, your care provider may suggest some options to promote labor. You may be told to walk or to return home and rest. Often, the most effective treatment for a prolonged early phase is rest. A medication may be given to help you rest.

Prolonged active labor Your labor may go smoothly during the early phase, only to slow down during the active phase of labor. Labor is considered prolonged if the cervix doesn’t dilate approximately 1 cm or greater an hour, after reaching 4 to 5 cm dilation. Progress may continue but take too long or it may stop or dwindle. An abrupt halt in progress following good contractions can suggest an incompatibility between the size of your pelvis and the size of your baby’s head.

Treatment If you’re making some progress in active labor, your care provider may allow your labor to continue naturally. He or she may suggest that you walk or change positions to assist in labor. You’ll likely be given fluids intravenously, to keep you hydrated, if you’re having a long labor.

However, if you’ve been in active labor and you haven’t made any progress for several hours, your care provider may start oxytocin, rupture the amniotic sac, or both, in an attempt to move things along. These steps are often enough to restart contractions and allow you to deliver without complications.

Prolonged pushing At times, efforts to push the baby through the birth canal are slow or aren’t effective, which can result in exhaustion on the mother’s part. If this is your first baby, pushing for more than three hours is generally considered to be prolonged. If you’ve already had a child, pushing more than two hours is prolonged.

Treatment Your care provider will evaluate how far down the birth canal the baby has descended and if the problem can be corrected by readjusting baby’s head position. If you’re able to continue and your baby isn’t showing signs of distress, you may be allowed to push for a longer time. Sometimes, if baby is descended far enough, his or her head can be eased out with the use of forceps or a vacuum extractor. You may be asked to try a semisitting, squatting or kneeling position, which can help to push the baby out. If your baby is too high in the birth canal and other measures won’t help, cesarean delivery may be needed.

ASSISTED BIRTH

If labor is prolonged or complications develop, you may require some medical assistance. Instruments — such as forceps or a vacuum extractor — can be used to help with delivery if your cervix is fully dilated and baby has descended, but is having difficulty making the last step to delivery. An assisted delivery may also be necessary if your baby’s head is facing the wrong direction and is wedged in your pelvis. If your baby’s heart rate is too low and baby must be delivered quickly or you’re too exhausted to push any longer, your care provider may intervene medically with a forceps- or vacuum-assisted birth. A forceps or vacuum-assisted delivery can be the quickest and safest means of delivering a baby.

Forceps-assisted birth Forceps are shaped like a pair of spoons that, when hooked together, resemble a pair of salad tongs. Your care provider gently slides one spoon at a time into your vagina and around the side of the baby’s head. The two pieces lock together, and the curved tongs cradle the baby’s head. While your uterus contracts and you push, the care provider gently guides the baby through the birth canal, which sometimes happens on the very next push or two.

Forceps are used today only when the baby’s head has descended well into the mother’s pelvis or is near the pelvic outlet. If the baby’s head hasn’t descended enough, a cesarean birth may be necessary.

Vacuum-assisted birth A vacuum extractor may be used instead of forceps, if baby has descended into the pelvis. A rubber or plastic cup is placed against the baby’s head, a pump creates suction, and your care provider gently guides the instrument to ease the baby down the birth canal while the mother pushes. The vacuum extractor cup doesn’t take as much room as forceps and is associated with fewer injuries to the mother. But a vacuum-assisted birth is slightly riskier for the baby.

What to expect An assisted delivery doesn’t take very long, but it may take 30 to 45 minutes to get you ready for the procedure. You may need an epidural or spinal anesthetic and a catheter placed in your bladder to empty it of urine. Your care provider may make a cut to enlarge the opening of the vagina (episiotomy) to help ease the delivery of the baby.

Instruments to help deliver babies are important tools and are generally safe. Be aware that forceps may leave bruises or red marks on the sides of your baby’s head. A vacuum extractor may leave a bruise or bump on the top of the head or cause bleeding in the baby’s scalp. The bruises take about a week to go away. A bump or red marks disappear within a few days. Serious damage with either technique is rare.

The choice of which approach to use — forceps or a vacuum extractor — is best left to your care provider. Experience with the instrument is the greatest defense against complications.

BABY IN AN ABNORMAL POSITION

Your labor and delivery may become complicated if your baby is in an abnormal position within your uterus — making vaginal delivery difficult or, sometimes, impossible.

Right around the 32nd to 34th weeks of pregnancy, most babies settle into a head down position for descent into the birth canal. As your due date nears, your care provider may determine the position of your baby simply by feeling your abdomen for clues as to the baby’s placement. He or she may also perform a vaginal exam or request an ultrasound. Sometimes an ultrasound exam is done during labor to determine the baby’s position.

If your baby isn’t positioned for an easy exit through your pelvis during labor, problems can develop.

Occiput posterior position

Facing up A baby’s head is widest from the front to the back. Ideally, its head should turn to one side once it enters the top of the pelvis. The chin is then forced down to the chest so that the more narrow back of the head leads the way. After descending to the midpelvis, the baby needs to turn either facedown or faceup to align with the lower pelvis. Most babies turn facedown, but when a baby is facing up, labor may progress more slowly. Care providers call this the occiput posterior position. Intense back labor and prolonged labor may accompany this position.

Treatment Sometimes, changing your position can help rotate the baby. Your care provider might have you get on your hands and knees with your buttocks in the air. This position can cause your uterus to drop forward and the baby to rotate inside.

If this doesn’t work, your care provider might try to rotate the baby manually. By reaching through your vagina and using his or her hand as a guide, he or she can encourage the baby’s head to turn facedown. If this technique isn’t successful, your health care team can monitor your labor to determine whether your baby is likely to fit through your pelvis faceup or whether a cesarean birth would be safer. Most babies can be born face-up, but it may take a bit longer.

Abnormal angle When a baby’s head enters the pelvis, ideally the chin should be pressed down onto the chest. If the chin isn’t down, a larger diameter of the head has to fit through the pelvis. However, a baby can enter the birth canal with the top of the head, the forehead or even the face presenting first — none of which is a preferred position.

If your baby’s head moves through your pelvis at an abnormal angle, it can affect the location and intensity of your discomfort and the length of your labor.

Treatment A cesarean birth (C-section) may be necessary if your baby isn’t progressing down the birth canal or shows signs he or she isn’t tolerating labor.

Head too big When a baby’s head can’t fit through the pelvis, the problem is called cephalopelvic disproportion. It may be that the baby’s head is too big, or the mother’s pelvis is too small. Or it may be more that the baby’s head isn’t properly aligned and the smallest width isn’t leading the way. No matter what’s causing the problem, labor can’t progress or the cervix may not dilate normally. The result is prolonged labor.

Treatment Size alone isn’t the only factor to determine if your baby will fit through your pelvis. The forces of labor can temporarily mold a baby’s head, even when poorly positioned, to fit through the pelvis, and loosened ligaments that occur with pregnancy allow the bones of the pelvis to open wider. Because of these variables, the best way for your care provider to find out whether your baby’s head is a match to the roominess of your pelvis is to monitor your labor as it progresses. If necessary, a C-section may be performed.

Breech A baby is in the breech position (presentation) when the buttocks or one or both feet enter the pelvis first. Breech presentation poses potential problems for the baby during birth, which can, in turn, create complications for you. A prolapsed umbilical cord is serious and more common in breech births. In addition, it’s impossible to be certain whether the baby’s head will fit through the pelvis. The head is the largest and least compressible part of the baby. Even if the baby’s body has already delivered, the head could become trapped.

Three examples of breech presentation

Treatment If your care provider knows prior to labor and delivery that your baby is breech, he or she may try to turn the baby into the proper position. This technique is called an external version. If the baby isn’t too far down in the pelvis, your care provider might be able to move the baby into a head down position simply by guiding the baby’s head so that the baby does a forward or backward somersault.

If the external version doesn’t work, a C-section will likely be necessary. Although most babies born breech are fine, current evidence indicates that a C-section is generally safer for most babies in breech presentation. An exception may be the second baby in a set of twins who is in a breech position.

Lying sideways A baby that’s lying crosswise (horizontally, or transverse) in the uterus is in a position called transverse lie.

Transverse lie

Treatment Just as in breech presentation, your doctor may try to turn the baby. This step is often successful. Babies who remain in this position need to be delivered by C-section.

INTOLERANCE OF LABOR

A baby is considered to be intolerant of labor if he or she persistently demonstrates signs suggesting a decreased oxygen supply, which the baby is having trouble adjusting to. These signs are usually detected by studying the fetal heart rate on an electronic monitor. Decreased oxygen to the baby usually occurs when blood flow from the placenta to the baby is reduced, meaning that he or she isn’t receiving enough oxygen from the mother.

Potential causes for this problem include compression of the umbilical cord, decreased blood flow to the uterus from the mother and a placenta that’s not functioning correctly.

Umbilical cord prolapse If the umbilical cord slips out through the opening of the cervix, blood flow to the baby may be slowed or stopped. Umbilical cord prolapse is most likely to occur with a small or premature baby, with a baby who is breech, with a very high amount of amniotic fluid, or when the amniotic sac breaks before the baby is down far enough in the pelvis.

Umbilical cord prolapse

Treatment If the cord slips out after you’re fully dilated and ready to push, a vaginal delivery may still be possible. Otherwise, a C-section is usually the best option.

Umbilical cord compression If the umbilical cord becomes squeezed between any part of the baby and the mother’s pelvis, or if there’s a decreased amount of amniotic fluid, the umbilical cord can become pinched (compressed). Blood flow to the baby is slowed or, very rarely, stopped, for a very short period during a contraction. The condition usually develops when the baby is well down the birth canal. If cord compression is prolonged or severe, the baby may show signs of decreased oxygen supply.

Treatment To minimize the problem, you may be asked to change positions during labor in order to move the position of the baby or the umbilical cord. You may be given oxygen to increase the amount of oxygen the baby gets. Your care provider may also try to infuse sterile saline into your uterus to reduce the cord compression, a therapy called amnioinfusion. It may be necessary for your care provider to get the baby out with forceps or a vacuum extractor. If the baby is too high in the birth canal or you aren’t completely dilated, a C-section may be necessary.

Decreased fetal heart rate With uterine contractions, the flow of blood through the uterus decreases as the contraction strength peaks. Babies can generally tolerate these temporary changes in blood flow with reserves that nature has provided. But if the reserves are surpassed, changes in the fetal heart rate may signal that the baby can no longer compensate for the interruption in oxygen supply. That’s why your baby’s heartbeat is monitored regularly during labor. If your baby’s heart beat is persistently too rapid or too slow, it may mean that he or she isn’t receiving enough oxygen.

By using an electronic fetal monitor, your care provider can pick up heartbeat irregularities that may indicate concern. Methods of fetal monitoring include:

External monitoring In external monitoring, two wide belts are placed around your abdomen. One is put high on your uterus to measure and record the length and frequency of your contractions. The other is secured across your lower abdomen to record the baby’s heart rate. The two belts are connected to a monitor that displays and prints both readings at the same time so that their interactions can be observed.

Internal monitoring Internal monitoring can be done only after your water has broken. Once your amniotic sac has ruptured, your care provider can actually reach inside your vagina and dilated cervix to touch the baby. To more accurately monitor the baby’s heart rate, a tiny wire is attached to baby’s scalp. To measure the strength of contractions, the doctor inserts a narrow, pressure-sensitive tube between the wall of your uterus and the baby. The tube responds to the pressure of each contraction. As with external monitoring, these devices are connected to a monitor that displays and records the readings, as well as amplifies the sound of your baby’s heartbeat.

Fetal stimulation test Ordinarily, when a baby’s scalp is touched or tickled by a care provider’s touch, the baby will move around, and his or her heart rate will go up. Sound may also be used to stimulate a baby. A baby who is stimulated and who doesn’t experience an increase in heart rate may not be getting enough oxygen.

Treatment. There are ways to help a baby get more oxygen. Your care provider may give you medication during labor to slow or stop your contractions, which increases blood flow to the fetus. If your blood pressure is low, you may be given a medication to increase it. You may also be given extra oxygen to breathe.

In most cases, labor should be allowed to continue, even when there are signs the baby is responding to temporary stress.

In extreme situations, oxygen deprivation can be life-threatening. Your care provider is trained to identify the signs of severe distress and take immediate action, which generally involves emergency cesarean delivery.

If you’re concerned by what you see on a fetal monitor, ask a member of your health care team. Don’t be surprised if what you see isn’t of great concern. Reading fetal monitors isn’t easy. Some drastic changes may not be cause for worry and some subtle ones may be very serious.