Childbirth Complications Childbirth Complications Save This Article For Later Share this: Font size: AAA WebMD

Feature A pregnancy that has progressed without any apparent hitch can still give way to complications during delivery. Here are some of the most common concerns. Failure to Progress (Prolonged Labor) A small percentage of women, mostly first-time mothers, may experience a labor that lasts too long. In this situation, both the mother and the baby are at risk for several complications including infections. Abnormal Presentation Presentation refers to the position the fetus takes as your body prepares for delivery, and it could be either vertex (head down) or breech (buttocks down). In the weeks before your due date, the fetus usually drops lower in the uterus. Ideally for labor, the baby is positioned head-down, facing the mother's back, with its chin tucked to its chest and the back of the head ready to enter the pelvis. That way, the smallest possible part of the baby's head leads the way through the cervix and into the birth canal. Because the head is the largest and least flexible part of the baby, it's best for it to lead the way into the birth canal. That way there's little risk the body will make it through but the baby's head will get hung up. In cephalopelvic disproportion, the baby's head is often too large to fit through the mother's pelvis, either because of their relative sizes or because of poor positioning of the fetus. Sometimes the baby is not facing the mother's back, but instead is turned toward her abdomen (occiput or cephalic posterior). This increases the chance of painful "back labor," a lengthy childbirth or tearing of the birth canal. In malpresentation of the head, the baby's head is positioned wrong, with the forehead, top of the head or face entering the birth canal, instead of the back of its head. Some fetuses present with their buttocks or feet pointed down toward the birth canal (a frank, complete or incomplete/footling breech presentation). Breech presentations are normally seen far before the due date, but most babies will turn to the normal vertex (head-down) presentation as they get closer to the due date. In a frank breech, the baby's buttocks lead the way into the pelvis; the hips are flexed, the knee extended. In a complete breech, both knees and hips are flexed and the buttocks or feet may enter the birth canal first. In a footling or incomplete

breech, one or both feet lead the way. A few babies lie horizontally (called transverse lie) in the uterus, which usually means the shoulder will lead the way into the birth canal rather than the head. Abnormal presentations increase a woman's risk for injuries to the uterus or birth canal, and for abnormal labor. Breech babies are at risk of injury and a prolapsed umbilical cord. Transverse lie is the most serious abnormal presentation, and it can lead to injury of the uterus (ruptured uterus) as well as fetal injury. Your doctor will determine the presentation and position of the fetus with a physical examination. Sometimes a sonogram helps in determining the fetus' position. When a baby is in the breech position before the last six weeks to eight weeks of pregnancy, the odds are still good that the baby will flip. However, the bigger the baby gets and the closer you get to the due date, the less room there is to maneuver. Doctors estimate that about 90% of fetuses who are in a breech presentation before 28 weeks will have turned by 37 weeks, and over 90% of babies who are breech after 37 weeks will most likely stay that way. Childbirth Complications Childbirth Complications (continued) Save This Article For Later Share this: Font size: AAA Umbilical Cord Prolapse The umbilical cord is your baby's lifeline. Oxygen and other nutrients are passed from your system to your baby, through the placenta and the umbilical cord. Sometimes before or during labor, the umbilical cord can slip through the cervix, preceding the baby into the birth canal. It may even protrude from the vagina. This is dangerous because the umbilical cord can get blocked and stop blood flow through the cord. You will probably feel the cord in the birth canal and may see it if it protrudes from your vagina. This is an emergency situation. Call an ambulance to get you to the hospital. Umbilical Cord Compression Because the fetus moves a lot inside the uterus, the umbilical cord can get wrapped and unwrapped around the baby many times throughout the pregnancy. While there are "cord accidents" in which the cord gets twisted around and harms the baby, this is extremely rare and usually can't be prevented. Sometimes the umbilical cord gets stretched and compressed during labor, leading to a brief decrease in the flow of blood within it. This can cause sudden, short drops in the fetal heart rate, called variable decelerations, which are usually

picked up by monitors during labor. Cord compression happens in about one in 10 deliveries. In most cases, these changes are of no major concern and most babies quickly pass through this stage and the birth proceeds normally. But a cesarean section may be necessary if the heart rate worsens or the fetus shows other signs of distress, such as decrease of fetal blood pH or passing of the baby's first stool (meconium). Causes and Treatments Failure to Progress (Prolonged Labor) Failure to progress refers to labor that does not move as fast as it should. This could happen with a big baby, a baby that does not present normally or with a uterus that does not contract appropriately. But more often than not, no specific cause for "failure to progress" is found. If labor goes on too long, your doctor may give you intravenous fluids to help prevent you from getting dehydrated. If the uterus does not contract enough, he or she may give you oxytocin, a medicine that promotes stronger contractions. And if the cervix stops dilating despite strong contractions of the uterus, a cesarean section may be indicated. Abnormal Presentation Sometimes a placenta previa may cause an abnormal presentation. But many times the cause is not known. Towards the end of your third trimester, your doctor will check the presentation and position of your fetus by feeling your abdomen. If the fetus remains in breech presentation several weeks before the due date, your doctor may attempt to turn the baby into the correct position. Childbirth Complications Childbirth Complications (continued) Save This Article For Later Share this: Font size: AAA Abnormal Presentation continued... One option typically offered to women after 36 weeks is an "external cephalic version," which involves manually rotating the baby in cog-like fashion inside the uterus. These manipulations work about 50% to 60% of the time. They're usually more successful on women who have given birth previously because their uteruses stretch more easily. "Versions" typically take place in the hospital, just in case an emergency cesarean delivery becomes necessary. To make the procedure easier to perform, safer for the baby and more tolerable for the mother-to-be, doctors sometimes administer a uterine muscle relaxant, then use an ultrasound machine

and electronic fetal monitor as guides. The procedure typically doesn't involve anesthesia, but sometimes an epidural can help with the version. Since not all doctors have been trained to do versions, you may be referred to another obstetrician in your area. There is a very small risk that the maneuver could cause the baby's cord to become entangled or the placenta to separate from the uterus. There's also a chance that the baby might flip back into a breech position before delivery, so some doctors induce labor immediately. The risk of reverting to breech is lower closer to term, but the bigger the baby, the harder it is to turn. The procedure can be uncomfortable, but avoids a cesarean section, which is most likely if the baby can't be moved into the proper position. Umbilical Cord Umbilical cord prolapse happens more often when a fetus is small, preterm, in breech (frank, complete or incomplete/footling) presentation, or if its head hasn't entered the mother's pelvis yet ("floating presenting part"). This prolapse can occur, too, if the amniotic sac breaks before the fetus has moved into place in the pelvis. Umbilical cord prolapse is an emergency. If you are not at the hospital when it happens, call an ambulance to take you there. Until help arrives, get on your hands and knees with your chest on the floor and your buttocks raised. In this position, gravity will help keep the baby from pressing against the cord and cutting off his or her blood and oxygen supply. Once you get to the hospital, a cesarean delivery will probably be performed unless a vaginal birth is already progressing naturally. Umbilical Cord Compression Umbilical cord compression can occur if the cord becomes wrapped around the baby's neck or if it is positioned between the baby's head and the mother's pelvic bone. You may be given oxygen to increase the amount available to your baby. Your doctor may hurry along the delivery by using forceps or vacuum assistance, or in some cases, delivering the baby by cesarean section.

ommon Birth Complications

Even if your pregnancy was smooth sailing all the way, it is still possible that you may encounter one of several different types of birth complications. These complications can happen for a number of reasons, and it is important to understand that as long as you have proper medical care, you and your baby will be just fine. To help you prepare for what could occur, below are the most common types of birth complications. Labour that is Prolonged or Fails to Progress: For some women, especially those who are having their first baby, labour can last far too long. This places the baby and the mother at risk for serious issues such as infections. To help the process along, oxytocin may be administered to promote contractions that are more productive. In some cases, a c-section may be needed if the cervix ceases to dilate completely. Presentation that is Abnormal: Any time the baby is not positioned properly, such as in the breech position, this is referred to as an abnormal presentation. The ideal position for the baby to be delivered is head down, facing the mothers back, with the back of the head against the pelvis and the chin tucked down into the chest. This allows the baby to easily travel down the birth canal. If the baby is not in this position for any reason, intervention will be needed to ensure the baby is safely delivered. Breech babies are often found well before the due date, and can be dealt with before complications arise. In some cases, the baby can be manipulated and turned to correct the positioning, and in other cases, the use of a vacuum assist, forceps, or a c-section may be needed for complete safety. Prolapsed Umbilical Cord: The baby depends completely on the umbilical cord for survival. All of the necessary nutrients and oxygen are supplied through the cord and the placenta so it is critical that nothing happen to disrupt this flow. That being said, there are times either before or during labor that part of the umbilical cord can slide through the opening of the cervix, and may even be seen outside of the vagina. This becomes quite serious because it can cut off the blood supply to the baby. No time should be wasted when this occurs, as this

is a medical emergency. In most cases, unless a vaginal delivery is well underway, a c-section will be needed to safely deliver the baby. Compression of the Umbilical Cord: Because babies tend to move a great deal in the womb, the cord gets wrapped and unwrapped around the body of the baby several times. Even though situations where the cord gets wrapped around the baby and causes harm do happen, they are quite rare. During labor, there are times when the cord gets compressed or stretched, which can decrease the blood flow for a short time, leading to fetal heart rate decreases. For the most part, these issues cause no major problems, and birth can proceed without further concern. However, if the fetal heart rate does not recover properly, or there are other signs of the baby being in distress, a csection will be needed immediately. While the above mentioned complications may make you feel a bit anxious about delivery, you must remember they are not the norm, and the majority of births go off without a hitch. If you have any specific concerns, be sure to discuss them in advance with your doctor or midwife. Profile of maternal and foetal complications during labour and delivery among women giving birth in hospitals in Matlab and Chandpur, Bangladesh.(Report)

Journal of Health Population and Nutrition June 1, 2012 | Huda, Fauzia Akhter; Ahmed, Anisuddin; Dasgupta, Sushil Kanta; Jahan, Musharrat; Ferdous, Jannatul; Koblinsky, Marge; Ronsmans, Carine; Chowdhury, Mahbub Elahi | Copyright Permalink INTRODUCTION Giving birth should be a time for celebration; however, for an estimated 358,000 women worldwide, pregnancy and childbirth end in death and mourning (1,2). Beyond these maternal deaths are numerous episodes of acute maternal complication: by some estimates, 9-10% of pregnant women or about 14 million women per year suffer from acute maternal complications (2,3). Estimate of the World Health Organization (WHO), United Nations Children's Fund, and United Nations Population Fund (approximately 15% of expected births suffering from obstetric complications) is more than double this figure: approximately 20 million women suffer from an obstetric complication. The consequences of birth

and acute maternal complications, including death and disabilities, make up the largest burden of disease affecting women in developing countries (4-6). In Bangladesh, an estimated 11,000-21,000 women die each year due to pregnancy-related complications (7), and a further 320,000 women suffer from injuries or disabilities caused by these complications during pregnancy and childbirth (8). Although most of these injuries or disabilities are not lifethreatening, these may render women outcast from their family and society. Women with disabilities may also face cultural, social or other barriers to obtaining care and, therefore, become silent sufferers (9-11). Measuring acute maternal complication is difficult, particularly in populations where not all women give birth in a hospital. The number and percentage of women in Bangladesh who suffer from acute maternal complications or medium or long-term disabilities are not yet known. The reliability of reported complications based on a woman's recall is poor, even if the woman suffered from a life-threatening complication (12,13). Reliable ascertainment of maternal complication requires observation by a trained service provider, and this is typically facility-based. For this reason, few studies have been able to measure the incidence of acute maternal complications at the population level (14,15). The aim of the present study was to document the types and severity of acute maternal and foetal complications among women admitted to different hospitals around the time of childbirth and post-partum. MATERIALS AND METHODS Study area We conducted the study in the icddr,b service area in Matlab, a rural area located about 55 km southeast of Dhaka, the capital of Bangladesh. In 2007, the population in the study area was approximately 113,660 (16). The major sources of income are fishing and farming, and about two-thirds of women have received institutional education (16). The area has been under surveillance since 1966 for vital events (births, deaths, marriages, migration) by the village-based Community Health Research Workers (CHRWs). At the time of this study, the CHRWs visited each household bi-monthly to collect data on the reproductive health status of women and determined pregnancy, using a pregnancy-detection strip. Other CHRWs provided services from fixed-site clinics bi-weekly, along

with counselling pregnant women to seek antenatal care and attend hospital for safe delivery. These CHRWs also disseminated information to groups of pregnant women about home-based lifesaving skills for newborns, including management of the newborns during normal delivery and for maternal and neonatal complications, such as prolonged labour, excessive bleeding, and birth asphyxia (17-19). The icddr,b service area has four subcentre clinics run by nurse-midwives and paramedical staff and a hospital in Matlab town with a 30-bed maternity unit run by doctors and nurses (16). Each subcentre clinic serves about 20,000 persons. They provide limited obstetric services 24 hours, including care for normal labour and delivery, the first dose of antibiotic for infection, the first dose of magnesium sulphate (MgS[O.sub.4]) for eclampsia, and oxytocin only for active management of third stage of labour (AMTSL). When necessary, they refer women with complications to the Matlab Hospital of icddr,b where the staff members provide all components of basic emergency obstetric care (EmOC), including manual removal of the placenta, assisted delivery, oxytocin for AMTSL, MgS[O.sub.4], and sedatives for eclampsia, and removal of retained products. Complicated cases not manageable at the Matlab Hospital are referred to the public and private hospitals in Chandpur district town where services can be reached in about 40 minutes by motorized transport and in about one hour by three-wheelers from Matlab; icddr,b offers free transportation to all the patients referred but management of patients in hospitals in Chandpur is not part of the responsibility of icddr,b. Study population We targeted all pregnant women in the icddr,b service area in Matlab, who gave birth during 2007-2008. Definition of maternal complications Information on maternal complications was collected for all women who were admitted during labour or up to 42 days postpartum to any of the following hospitals: the Matlab Hospital of icddr,b, one public hospital in Matlab, and two public and 26 private hospitals in Chandpur district.

We aimed at classifying women by the severity of maternal complications, using three groups: severe maternal complication, less-severe maternal complication, and vaginal delivery without any maternal complication. The definition of severe maternal complication was adapted from the definitions of near-miss and lifesaving surgery proposed in the literature (20). Women with maternal complications were classified by primary diagnosis only, giving precedence to haemorrhage, hypertensive disorders of pregnancy, infection, anaemia, and dystocia sequentially. Indications for CS were classified using the classification proposed by Stanton et al. (21). Some women had given birth by CS without a reported maternal complication; these were included in a category of CS without any maternal complication. Lastly, we added a category of foetal complication, regardless of whether or not women had a maternal complication (Table 1). Data-collection As part of the regular responsibilities, the CHRWs generated a list of pregnant women, using the women's unique identifiers. They collected information within one or two week(s) of a pregnancy outcome on all pregnant women during 20072008, including the place of birth, and the name and location of the hospital if any admission took place during delivery or immediately postpartum. Admissions to more than one hospital were noted. They also noted whether the child was born alive and survived or not until the first week of life. A physician searched the hospital-records for any Matlab woman admitted during labour or postpartum to the Matlab Hospital, or any of the public or private hospitals in Matlab or Chandpur, including the admission registers and individual patient-records. Admissions were classified by maternal or foetal Delivery practices of traditional birth attendants in Dhaka Slums, Bangladesh.(Report)

Journal of Health Population and Nutrition December 1, 2007 | Fronczak, N.; Arifeen, S. E.; Moran, A. C.; Caulfield, L. E.; Baqui, A. H. |Copyright Permalink ABSTRACT

This paper describes associations among delivery-location, training of birth attendants, birthing practices, and early postpartum morbidity in women in slum areas of Dhaka, Bangladesh. During November 1993-May 1995, data on deliverylocation, training of birth attendants, birthing practices, delivery-related complications, and postpartum morbidity were collected through interviews with 1,506 women, 489 home-based birth attendants, and audits in 20 facilities where the women from this study gave birth. Associations among maternal characteristics, birth practices, delivery-location, and early postpartum morbidity were specifically explored. Self-reported postpartum morbidity was associated with maternal characteristics, delivery-related complications, and some birthing practices. Dais with more experience were more likely to use potentially-harmful birthing practices which increased the risk of postpartum morbidity among women with births at home. Postpartum morbidity did not differ by birthlocation. Safe motherhood programmes must develop effective strategies to discourage potentially-harmful home-based delivery practices demonstrated to contribute to morbidity. Key words: Birth practices; Community studies; Delivery; Maternal health; Postpartum morbidity; Prospective studies; Traditional birth attendants; Bangladesh INTRODUCTION Postpartum morbidity is common among women in Bangladesh. A national survey showed that 24% of women reported at least one complication during the postpartum period (1), while two studies in urban slum areas of Dhaka, Bangladesh, demonstrated that approximately 75% of women reported at least one postpartum morbidity (2,3). The World Health Organization (WHO) currently recommends that all births are assisted by a skilled attendant to address unacceptably high levels of maternal mortality and morbidity (4). In Bangladesh, although women living in urban slum areas of Dhaka reside in close proximity to facilities with skilled care, 70% of women in urban areas give birth at home with non-medically trained providers (5) which is likely to be even higher in urban slums. Postpartum morbidity can be attributed to (a) maternal heath status prior to pregnancy; (b) conditions which develop during pregnancy; and (c) complications or conditions which occur as a result of childbirth. Other factors

that influence postpartum morbidity include maternal traits, such as primiparity, grand-multiparity, and short stature, and socioeconomic factors, such as poverty, access to care, and low education (6-11). The level of training of birth attendants and the management of complications by both home and facility-based attendants can contribute to postpartum morbidity (7,9-11). Harmful practices for childbirth include: giving birth on a dirty surface; lack of hand-washing by the birth attendant; guarding the perineum with the foot; frequent vaginal examinations; and traditional methods commonly used to stop bleeding, such as pressure on the abdomen with hand, knee, stool, or other objects, and methods to hasten delivery of the infant or to expel the placenta (1216). Other delivery practices, such as using oxytocic drugs to augment labour, internal version to re-position malpositioned infants, and manually removing the placenta, are considered unsafe if used by untrained persons (12-16). Previously, a high incidence of self-reported delivery-related complications was documented among 1,506 women living in urban Dhaka (2). In this paper, the types of delivery-care providers used by these women, their training and experience, and reported birthing practices are described. Specifically, the associations among place of delivery, training and experience of home-delivery providers, childbirth practices, and postpartum morbidity were explored. MATERIALS AND METHODS This community-based prospective study was conducted in 424 clusters of 25-50 households in five selected low-income upazilas (administrative areas) of Dhaka city, the capital of Bangladesh. Slum clusters were chosen using a multistage probability-sampling methodology. Women who completed at least seven months of pregnancy and who planned to give birth in Dhaka were eligible for the study. During November 1993-May 1995, trained data collectors interviewed pregnant women in their homes in these households (n=1,506) at seven months gestation and at 72 hours and seven days postpartum. At 14-22 days postpartum, trained female physicians interviewed and examined women. In these interviews, information on economic status, prior history of pregnancy, self-reported complications, childbirth experience, place of delivery, and self-reported postpartum morbidities was collected. Information collected previously at 72 hours and 14-22 days postpartum was used for categorizing self-reports of delivery-related complications and subsequent postpartum morbidity using

operational definitions (2). Here, this morbidity information is linked to the labour and delivery experience reported by the mother at 72 hours postpartum. Home-based birth attendants identified by study women were interviewed regarding formal training and experience in conducting deliveries. Data were also collected from 20 facilities where the study women delivered, including equipment, supplies, and clinical records of complications and morbidity. The interview at 72 hours postpartum began with open-ended questions to elicit a narrative description of the woman's delivery experience from the onset of labour pains until delivery. Structured questions were then asked about the home-based birth attendant, materials used during delivery, any interventions or practices that occurred during the delivery, specific management of the retained placenta, and information on emergency transfers to a health facility. The nutritional status was assessed by calculating body mass index (BMI=weight (kg) / height [(m).sup.2]) from measures taken at seven days postpartum. Undernutrition was defined as BMI <18.5