Complications of Childbirth
This lesson provides an advanced overview of complications that can arise during childbirth, offering critical insights for prehospital emergency medicine providers. While childbirth is a natural process, being prepared for and recognizing these complications is essential for ensuring positive outcomes for both mother and newborn.
Complications Before Labor
Premature Rupture of Membranes (PROM): Amniotic sac ruptures more than an hour (or a few hours) before labor begins. This increases the risk of infection, especially if not near term.
Preterm Labor: Labor beginning after the 20th but before the 37th week of pregnancy.
Fetal Distress: Difficult to assess in the field. Women may report decreased or absent fetal movement. Transport and supportive care are indicated.
Intrauterine Fetal Death: Fetus dies in utero before labor. Care focuses on maternal support. Do not attempt to resuscitate an obviously dead fetus.
Hydramnios (Polyhydramnios): Too much amniotic fluid. Increases risk for prolapsed cord, abruptio placenta, and postpartum hemorrhage.
Cephalopelvic Disproportion (CPD): Fetal head is too large for the maternal pelvis. Labor will not progress, requiring C-section. Consider this if delivery is not progressing and transport to appropriate facility.
Complications During Labor and Delivery
1. Uterine Rupture:
A tear in the wall of the uterus, typically occurring during labor.
Signs/Symptoms: Weakness, dizziness, thirst, initial strong contractions followed by sudden cessation or lessening of contraction strength. Patient presents with signs of hypovolemic shock.
Management: Rapid transport to a receiving facility. Treat for hypovolemic shock (O2, IV fluids if ALS, keep warm).
2. Precipitous Labor and Birth:
Labor and birth lasting less than 3 hours. More common in multiparous women.
Management: Prepare for rapid delivery. Control the delivery to prevent maternal tearing and neonatal injury. Assess mother for tears and bleeding post-delivery.
3. Postterm Pregnancy:
Fetus not born after 42 weeks. High risk for fetus due to potential malnourishment and meconium aspiration.
Meconium Aspiration: First stool passed by fetus, can be aspirated, causing chemical pneumonia in newborn. Assess amniotic fluid color (greenish-black) during delivery.
Fetal Macrosomia: Fetus weighing >4500 grams. Higher risk of birth complications. Monitor newborn glucose post-delivery.
4. Multiple Gestation:
Presence of more than one fetus.
Management: Prepare for multiple resuscitations. Identify newborns (Baby A, Baby B). Record separate Apgar scores and birth times. Note if one or two cords emerge from the placenta(s).
5. Cephalic Presentation Abnormalities:
Fetal head presenting in an extended or abnormal position (e.g., brow, face, military).
Management: Support woman and fetus. Rapid transport to receiving facility if external rotation or delivery cannot be completed. Do not attempt field delivery for these presentations.
6. Breech Presentation:
Fetus presents buttocks or feet first.
Types: Frank breech (buttocks first), complete breech (buttocks and feet first), footling breech (one or both feet first).
Management: If buttocks are presenting and delivery is imminent, assist. Position woman with buttocks at edge of bed/stretcher, legs flexed. Support newborn's body. If head does not deliver within 3 minutes, newborn may suffocate (advanced procedure training often required for specific interventions). Do not attempt field delivery for footling breech or other non-frank breech presentations; rapid transport indicated.
7. Shoulder Dystocia:
Difficulty delivering the fetal shoulder after the head has been delivered.
Risk: Brachial plexus injury to newborn, fetal asphyxia.
Management (McRoberts Maneuver): Hyperflex maternal legs tightly to abdomen. Apply slight suprapubic pressure. This helps rotate the shoulder beneath the symphysis pubis.
8. Nuchal Cord:
Umbilical cord wrapped around the newborn's neck.
Management: Gently slide a gloved finger under the cord and attempt to slip it over the head. If unsuccessful or tight, clamp and cut the cord (two clamps, cut between). Prepare for immediate ventilation of the newborn.
9. Prolapsed Umbilical Cord:
Cord emerges before the fetus, compressing blood supply.
Management: Immediate intervention. Position woman supine with hips elevated. Administer O2 to mother. Gently push presenting fetal part back up into vagina to relieve pressure on cord. Insert gloved hand to create space around the cord if necessary. Do NOT attempt to push the cord back in. Maintain this position and transport emergently.
10. Uterine Inversion:
Uterus turns inside out, often with retained placenta. Can be partial or complete.
Signs/Symptoms: Painful, rapid progression to hypovolemic shock, internal bleeding.
Management: Keep patient recumbent. Administer O2, start two large-bore IVs (ALS). Do not attempt to remove placenta if still attached. Paramedics may attempt one gentle attempt to replace the uterus if patient is in hemorrhagic shock. Transport emergently.
Postpartum Complications
1. Postpartum Hemorrhage:
Blood loss exceeding 500 mL in first 24 hours (early) or up to 6 weeks post-delivery (late).
Causes: Uterine atony (most common), lacerations, retained placental fragments, multiple pregnancies, placenta previa, full bladder.
Management:
Uterine Massage: Fundal massage to encourage uterine contraction.
Breastfeeding: Encourages natural oxytocin release, promoting uterine contraction.
Oxytocin (ALS): Can be administered (10-20 units IV in infusion) to control hemorrhage if massage is ineffective.
Supportive Care: O2, IV fluids (if ALS), keep warm, monitor for shock. Rapid transport.
2. Amniotic Fluid Embolism:
Amniotic fluid enters maternal pulmonary circulation, causing an allergic-like reaction.
Signs/Symptoms: Respiratory distress, hypotension, cyanosis, seizures. If initial reaction survived, coagulopathies (DIC) may develop.
Management: Support respiratory and circulatory systems. Rapid transport.
Critical Thinking Questions
You are assisting in the field delivery of twins. What are your immediate priorities and how would your preparation differ from a single birth?
A woman in active labor experiences a sudden cessation of strong contractions, followed by signs of hypovolemic shock. What serious complication should you suspect, and what is your immediate management plan?
During a field delivery, the newborn's head delivers, but the shoulders become impacted. Describe the technique you would use to facilitate delivery and prevent fetal injury.
You encounter a patient with a prolapsed umbilical cord. Detail the critical steps to manage this emergency and optimize outcomes for the newborn.
A mother who just delivered presents with excessive vaginal bleeding despite fundal massage. What pharmacological intervention might an ALS provider consider, and what is the rationale behind it?